HIV Prevention Among Young Injecting Drug Users

United Nations Office on Drugs and Crime Vienna

HVI among PREVENTION young injecting drug urerr

UNITED NATIONS New York, 2004

The Office for Drug Control and Crime Prevention became the Office on Drugs and Crime on 1 October 2002.

UNITE D NAT IONS PUBLICATION Sales No. E.04.Xl.20 ISBN 92-1-148190-2

This publication has not been formally edited.

Acknowledgements

4

List of participants

5

Abbreviations

7

1. Background and purpose

9

Drug use and HIV/AIDS

9

The specific issues of young IDUs

11

Drug use patterns

14

Transition t o injecting

15

Risk behaviour and consequences

18

HIV/AIDS (and other STD's)

20

Specific risk groups

21

2. Step by step-how t o buitd a programme

27

Know the target group

28

Staff

30

Planning and involving youth

33

Corn munity

34

Estabtishing contact

37

What t o provide and how

38

Funding, monitoring and evaluating

56

3. Key principles for HIV prevention

59

4. Resources

63

Motes

65

3

I n coordination with the Brazilian National Ministry of Health, the National Coordination for HIV/AIDS prevention and the UNODC field office i n Brasilia, the Global Youth Network project organized a hands-on meeting for young people involved i n preventing HIV/AIDS amongst young Injecting Drug Users (IDU's). The meeting was held i n Cuiaba, capital of the Mato Grosso province of Brazil from 8-11 September 2001 i n tandem with the I V Brazilian Congress on the Prevention of STD and AIDS. Fourteen representatives from eight countries, from various service organizations working with injecting drug users met with the aim t o exchange ideas, t o facilitate communication, t o develop guidelines and t o formulate a set of best practices t o prevent injecting drug use, HIV and AIDS among youth. The workshop discussions and proceedings provided the framework for the formulation of these guidelines t o prevent injecting drug use and related adverse consequences, i n particular, prevention of blood borne pathogens like HIV among drug users and their sexual partners. I n particular we would like t o thank Tamara Maman, Dr. Shakuntala Mudaliar of SAHAI Trust (Chennai, India), Christian Kroll, Moruf Adelekan, Stefan0 Berterame, Giovanna Campello and Gautam Babbar for their work i n bringing this guide t o fruition. Various people contributed by providing comments and inputs, including UNICEF, WHO, UNFPA and UNAIDS. The Inter Agency Task Team on young people was also involved with the consultations. The reader will note that the term "harm reduction" i s used i n some of parts of the publication. From UNODC's point of view, this term is meant t o cover those activities aimed a t reducing the health and social consequences of drug abuse, an integral part of the comprehensive approach t o drug demand reduction, as recognized i n the Declaration on the Guiding Principles of Drug Demand Reduction, adopted by the United Nations General Assembly Special Session on the World Drug Problem i n 1998. Within this document, the three following areas of activity are referred t o as "harm reduction principles": Reaching out t o injecting drug users; Discouraging the sharing of contaminated injecting equipment by providing sterile injecting equipment and disinfectant materials; Providing substitution treatment. These principles, which were first enunciated i n "Principles for preventing H I V infection among drug users" by WHO, together with UNAIDS and the Council of Europe, i n 1998, should not be seen i n isolation from overall national drug strategies or national AIDS programmes. They are, however, valuable i n guiding these national policies and programmes with regard t o the specific goal of reducing HIV transmission among injecting drug users. (WHO, 1998: Principles for preventing H I V infection among drug users, Copenhagen: WHO Regional Office for Europe).

4

I n addition t o the above documents, the guiding policy document of UNODC's current activities i n this work area i s the ACC-approved document titled "Preventing the transmission of HIV among drug abusers: A position paper of the United Nations System", which was also endorsed as a conference room paper (E/CN.7/2002/CRP.5) at the 2002 meeting of the Commission on Narcotic Drugs (CND).

tiit of parti b IHTERCAMBIQS, ARGENTINA

BRAZIL Phone: +55-51-3225 37201 3231 7 2 1 4

Diego Santiltan Cornentes 2548-1O E-1046 Buenos Aires ARGENTINA [email protected] Phone: +54-11-4954 7272

SANTA CATAIIINA, BRAZIL %brina Iara Tomar

Fax: +54-11-49541333

Conqeiqio, 623 bairro: S o Jo3o-ltajai-Santa Catarina BRALIC

XCQN (INDO-CHINESE OUTREACH NETWORK), WDNfY, AUSTRALIA Penny Sargent School of Public Health and Community Medicine, Faculty of Medicine, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, AUSTRALIA. Phone: +61-2-93852503 Fax: + 61-2-9385 1526 trttp://home.ipn'mus.com .au/awwa/

i

i

BAHIA, BRAZIL Josirnar Concei~IoMelo CETAOJPRDCentro de Estudos e Terapia do Abuso de Drogas Rua Pedro Lessa 123, Canela Saivavador Bahia

BRAZlt

[email protected] Phone: 45-71-336 3322 Fax: +55-71-336 7643

STEPS TO A POSITIVE DIRECTION, SORA, BULGARIA Anna Pehlivanova 1504 I f Marim Drinov Str. Sofia 3U LGARIA Sofianep@online, bg Phone: +359-2-9864954/951 5963/943 3980 Fax: +359-2-9864954

S i 0 PAULO, BRAZIL Abelardo Furtado, Mendonp Filho Av. Conselheiro Nebias 116 (altos), Santos

YOUTH CO, VANCOUVER, CANADA Sheena Sargeant 203-319 West Pender Street Vancouver, British Columbia V6BlTF CANADA [email protected] [email protected] Phone: +I-614-688 1441 www.youthco.org

BRAZIL i

Slluia Femanda de Paula Rua Francisco de Souza Rezende no 330, Sao Paul0 BRAZIL [email protected]. br Phone: +55-13-3223 5624 Fax: 45-16-6382745

MAT0 GROSSO, BRAZIL Isabel Silva Magalhies Rua 13 de junho, 802 - Santa habe( - Cuiabd/MT BRAZIL [email protected] .br Phone: +55-65-634 4789

RIO GRANDE DO SUL,

T. Magar, Chennai

600 029 INDIA [email protected] Phone: +91-44-433 2285

ROMANIA bdriana Lungu Ancuta Adolescent Association Bucharest (Adolescentul Association) Moise Nicoara street no. 8 741391 Bucharest 4 ROMANIA Adolesc@Rcnet. ro [email protected] Phone: GO-1-13238017

-

BRAZIL

Mauricio Pereira da Silva Rua Vhte e Urn, no 497 Bairro Born Jesus Port0 A k g r e J R S ,

INDIA Eardley Rigley Shakuntala Mudaliar 12 Vaidayaram Street

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5

YUGOSLAVIA Jelena Kostic Gandijeva 136 11070 Belgrade YUGOSlAVIA Phone: +381-11-781622/361 0776

UNODC VIENNA Stefano Berterarne Gaubm Babbar UNODC, PO BOX 500, A 1400, Vienna AUSTRIA

[email protected] Stefano. [email protected] http://www.unodc.arg/youthnet

UNAIDS Telva B a r n s Haiam, Garcia da Costa SCN, Q. 02, Bl. A, Ed. Corporate Financiat Center, Asa Worte,

Brasilia DF CEP: 70359-970 BRAZIL [email protected]

[email protected] Phone:+55-61-329 2195

Fax: +55-61-3292197

6

LINODC 3llAtIL Cintia Freitas Vera da Ros Giwanna Quaglia Nan Araufo UMOOC-Regional Ofice Minist&io da Justi~a,anexo I 70064-900 Brasilia DF BRAZIL [email protected]

Abbreviationr

7

ACC-Administrative

AIDS-Acquired

Committee on Coordination (UM)

Irnrnuno-Deficiency Syndrome

ATS-Amphetamine

Type Stimulants

CDC-Centers for Disease Control and Prevention CSW-Commercial Sex Work CLBT-Gay,

Lesbian, BisexuaL and Transgender

HN-Human

Immune-Deficiency Virus

ICON-hdo Chinese Outreach Network, Sydney, Australia IDU-Injecting

Drug Use

IDUs-Inject! ng Drug Users IEC-Information,

Education, Communication

MGO-Non-Governmental

Organization

and Syrr'nge Exchange Progmrnrnes

NSEP-Needle

PLWHA-People

Living With HIV/AIDS

STD-Sexually

Transmitted Disease

SI-Sexually

Transmitted Infections

UNAIDS-Joint

United Nations Programme on HIVJAIDS

UNFPA-United

Nations Fund for Population Activities

UJNGASS-United

Nations General Assembly Special Session

UNICEF-United

Nations Children's fund

UNODC-United

Nations Office On Drugs and Crime

WHO-World YMSM-Young

Health Organization men who have sex with men

7

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Background and purport Drug w e and HIV/AIDS Injecting Drug Use and HIVIAIDS The global HIV/AIDS epidemic killed more than 3 million people in 2003, and an estimated 5 million acquired the human immunodeficiency virus (HIVj-bringing t o 40 million the number of people living with the virus around the world [I]. Anywhere between a third and quarter of the 40 million people living with HIV/AIDS are i n the age group of 15-24 years. Some studies estimate that young people account for as many as half o f a l l new infections [2]. Worldwide, new infections i n young peop'le occur a t the rate of five per minute. Today, injecting drug use i s acknowledged i n 135 countries and it i s estimated that more than 3 million users are HIV-positive, whereas i n 2992, only 80 countries reported injection drug use, with only 52 reporting HIV infecting among injection drug users. Drug prevalence rates among youth can be three or four times higher than those found among the general population. This includes injecting drug use. Although it was common t o say t h a t IDU i s less common among adolescents, in some regions the age of IDU has decreased considerably, t o include adolescents and children.

9

According t o an 'UNAIDS 2000 report, it i s estimated t h a t between 5 and 10 per cent of HIV infections have resulted from injecting drug use globally. I n some countries and areas however, more than half of reported AIDS cases are attributed t o injecting drug use. For example Belarus, China, Italy, Poland, Spain, Russian Federation and Eastern Europe [3]. ma**...aa.*

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Facts around the world..

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In Central Asia, more than 80 per cent of new infections are related to IDUS. By some estimates, there could be as many as 3 million injecting drug users in the Russion Federation alone, more than 600,000 in Ukraine and up to ZU0,OUO in Kazakhstan. (In Estonia and Latvia, it has been estimated that up to 1 per cent of the o d d t population injects drugs, while, in Kyrgyzstan, that figure could approach 2 per cent). Most of these drug users are male and many are very young-in St Petersburg, studies found that 30 per cent of them were under 19 years of age, while, in Ukraine, 20 per cent were still in their teens [I].

In parts of China, for example, high rates of Hll//dIDS prevalence have been found among injem'nq drug users-35-80 per cent in Xinjiung and 20 per cent in Guangdong 121. According to official estimates, 65 per cent of I/iet #urn's HW infections are occum'ng among drug usen, due to the use of Contaminated injecting equipment. Sentinel surveillance in 2002 found that more than 20 per cent of injecting drug users in most provinces were HIV-positive 111. A report by the national programme for the struggk against AIDS and sexually transmitted diseases in Argentina, revealed that the transmission of HIV between IDUs represents 40 per cent of the total HIV/AIDS cases in the country [4J.

The most common modes of HIV transmission worZdwide remain unprotected sex, unscreened blood and blood products, contaminated needles, and mother-to-child transmission. I n many countries of Asia, Latin America, Europe and North America, injecting drug use i s the main or a major mode of HIV transmission. With an estimated 12.5 million peopie injecting drugs across the globe, most being between the ages of 1 5 and 30, there i s a huge potential for further spread of H I V among drug injectors and their sexual partners. S h a ~ n gor use of contaminated injecting equipment or needles i s the most efficient way of transmitting HIV. The level of risk i s much higher than from unprotected sexual intercourse since H I V infected material i s injected directly i n t o the bloodstream. Since injecting drug users are often linked i n tight networks and commonly share injection equipment, H I V can spread very rapidly i n these populations through sharing of injection equipment and through risky sexual behaviour.

Badground and purport

There is considerable evidence that public health interventions can change the course of epidemics. HIVJAIDS prevention programmes have helped make drastic changes i n whose injecting risk behaviour and also sex risk behaviour. Dramatically lowered levels of HIV inferh'on have often rewarded countries that have worked with young people t o reduce risky behaviour. m ~ . m * * 4 . ~ ~ 4 * * ~ . ~ m . m . ~ m 4 , 4 m a m m ~ * * * * ~ ~ ~ * * * ~ * e w ~ w , m ~ m a . ~ . * ~ * * * " ~ ~ ~ w ~ .a*

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"In regions like Eastern Europe

.. . we muId effect'vety stop the development of large-

scale (HIV) epidernicr through strong efforts targeting injecting drug users.M Peter mot, Executive Director of UNAIDS, June 2001.

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Injecting drug use and sexual behaviour Drug injectors are a t risk of g e t t h g infected with HIV virus and spreading the infection t o their sex partners through unsafe sex. Injecting drug users can act as a bridge t o transmit HIV t o non-injectors with which they have sexual contacts. IDUs tend t o underestimate the importance of condom use i n sexual intercourse and have very low levels of condom use. Numerous studies have found drug injectors t o be disproportionately likely t o be involved i n the sex industty. Girls, who have sex i n exchange for money or drugs, are a t high risk for HIV infection and can spread the virus t o a large number of people. I n addition t o sexual contact between drug injectors and non-injectors, drug injecting may also contribute t o an increased incidence of HIV infection through HIV transmission t o the children of drug injecting mothers (this i s called "vertical transmission"). HIV is also a risk among drug abusers who do not inject drugs through high-risk sexual behaviour. The impact of many types of psychoactive substances, whether injected or not, including alcohol, are risky t o the extent that they are disinhibitors and affect the individual's ability t o make decisions about safe sexual behaviour. .mmamamoe..

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New epidemics have emerged in Estonia and Uzbekistan, while in Ukraine, more than 250,000 people were living with HIV/AIDS by 2000. Although the epidemic is still concentrated among injecting drug users and their 5exuoL partners, growing prostitution and high level of sexudly transmitted infections could, in a dirnote of jalfing social change, cause it to spread rapidIy into the general population [6]. .e.ao*o*m.

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The speGfic issues of young IDUs You may be wondering why this manual focuses specifically on young IDUs and why it i s important t o differentiate young IDUs from others. The reason is that young IDUs are not the same a5 their older counterparts. We shoutd remember that youth are the adullts of the coming years and countries w i l l face economic and social instability if this group becomes the main concentration of HIVJAIOS cases. Various factors make their issues unique and these have raised awareness for the need t o have services, which target them specifically.

11

HIV prevcntion among young injetring drug urerr

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Peer influence: Youth are curious and can be easily influenced by peer pressure. They often use or abuse drugs within their peer groups and are often guided by the peer norm, where drugs may be considered normal. mom.*****.m*n.

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: "At the uge of 14 I a had friend who tried drugs, so I knew in full detail how drugs are *.

made and used. The very first injection grabbed hold of me and I began to do drugs regularly [JJ." Mma, Belarus *......*...ma.m,,e..*.**a.~*moe

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*: Limited awareness: Young IDUs often have limited education, awareness and knowledge of the HIV virus. Information and communication material that may be available i s often not written for young people. They may know little about the drugs, their effects, the risks associated with drug abuse, especially drug injection, safer injecting practices and reducing their risk behaviour. Young IDU have been found t o engage in higher levels of needle and syringe sharing than older I D U [8].A United Nations report released i n July 2002 reported that the vast majority of the world's young people have no idea how HI\( i s transmitted or how t o protect themselves from the disease. "Young people actually don't have the proper knowledge t o protect themselves. The tragic consequence i s that they are disproportionately falling prey t o H I V [9]." . 8 * 0 0 * 8 * * + * *o * ~ m m . * * . m 8 0 m a . . . 8 * ~ * ~ ~ g m ~ m . 8 . . * ~ * * 9 0 0 m m . . a m a 8 + m ~ m e a m * m

In countries with generalized HIV epidemics, such as Cameroon, Central Afrcon Republic. . . more than 80 per cent of young women aged 15 to 24 do not hove sufficient knowledge about HIV In Ukraine, although 99 per cent of girls had heard of AIDS, only 9 per cent could name three ways to ovoid infection 191. moe+8*mma.

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Unawareness of r i s k Risks t o health may be regarded as distant or remote as young IDUs do not experience the compLexity and severity o f health problems as often as they may be encountered by older IDUs who have injected for longer (abscesses, gangrene . . .). It may be difficult for young IDUs t o understand the need for prevention efforts when they have not experienced health problems as a result of their own injection drug use. Limited access to services: Services are often perceived by youth as unfriendly t o young people. Young IDUs are often unaware of the existence of health, social, legal and welfare services that could be of help t o them. They may not know how t o access these services. Some services are geographically inaccessible t o youth. Some countries have waiting list5 i n health services, and in hospitals-this can lead youth t o give up on receiving any help.

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Badtground and purp~e

tack of confidentiality at services: Young people, as well as adults i n this case, may feel ashamed, fear stigmatization or the lack of privacy and confidentiality when considering approaching treatment services. They may be afraid t o make their problem visible, and thus avoid using services. The desire t o keep the drug problem discrete results from the strong stjgma associated with drug use (and with HIVJAIDS), mentioned under social consequences.

.'. Economic instability:

While adult IDUs usually have an income (at least initially), youth often suffer from economic instability, as they are unemployed and often unskilled after dropping out of school. Many youths have t o resort t o crime or commercia[ sex work t o get money far drugs. lack of money may also prevent youth from seeking health care, as they may not be able t o afford care or medication that they would need t o buy.

The recent decades have seen a decrease i n the age of initiating drug use. This i s a concern, as the age of initiation of injech'on drug use is important i n assessing the severity of the associated risk. Trends seem t o indicate that youth are beginning injection at younger ages.

If a youth begins drug abuse very early, some additional problems arise because: At younger ages the individual is less likely t o understand the consequences o f his or her drug use. Early onset of drug use i s often connected t o polysubstance use.

The longer a person uses drugs, the more severe wilZ be the long-term health related consequences. Early onset wilt often mean school drop out and this will i n turn leave few career or job opportunities i n the future. Inability t o find employment can lead youth t o remain on the streets and i n the drug-using scene, Young girls, who usually have not completed school education, often end up in commercial sex work t o get money for drugs or t o get drugs directly.

Social consequences: Injecting (and non-injecting) drug use also brings social consequences with it. Consequences include dropping out from schoo!, family conflict resulting i n having t o leave the home, delinquency and social isolation. Since drug abuse i s illegal, IDU's usually try t o minimize contact with law enforcement agencies and officials. IDU is also stigmatized i n most societies, so there is a legitimate reason for the IDUs t o hide from society [ll].IDUs are isolated from the mainstream and usually do not come forward for help or information, even when this is available. Also, health services, treatment and counselling services are often designed for adults or addicts The needs of young people, especially those i n the early phases of their "drug careers", so t o speak, who often do not even consider tRemseCves addicts, are not catered for.

13

HI! prevention among young injecting drug u!err

Even amongst the broader group of drug users, young IDUs have special problems with the law. Their youth, often their status as juveniles and their marginalization often contribute t o law enforcement authorities being even more disrespectful discriminatory and brutal than they would be with drug users in general. . m e m * m q w m w m

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Nany countries in Eastern Europe and the former Soviet Union attempt to control injectihg drug use through harsh, inapproptiute measures. The police in some countries round up young people suspected of drug use to search f o r needle marks (known as "tracks") or force them to be tested f o r HI1 Those who test positive have their drug use and HIV status ofprciaLLy registered with the police. These measured not only have failed to reduce the negative health and social consequences of drug abuse but have forced IDUs further underground, encouraging needle sharing and other risky behaviours [12]. *m.mmmamm.

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For these reasons, IDUs are frequently referred t o as a "hard-to-reach" population. To maximize the chance o f S U C C ~ S Sfor H I V prevention, it i s important t o reach drug injectors i n the street and i n the places where they congregate, t o use former or current drug users as peer educators and t o win the cooperation of law enforcement officials SO that outreach strategies and programmes are tolerated. These approaches will be discussed i n section two. Finally, UTdAIDS [5] emphasise three main reasons t o single out young peopEe for H I V I A I D S prevention: The special vuinerability o f young people t o the epidemic. O f a l l those infected alfter infancy, a t least half are young people under 25, Young people account for hundreds of millions of people i n the developing wortd, where the epidemic i s concentrated. If HIV prevention i n this huge youthful population fails, developing countries WilL have t o face the staggering human and economic costs of vast numbers o f adult AIDS cases. Working with young people makes sense because they are a force for change. They are s t i l l a t the stage of experimentation and can learn more easily than adults t o make their behaviour safe or t o adopt safe practices from the start. Young people can change the course of the epidemic.

Drug use patterns Different parts of the world see different patterns of drug use and different trends regarding which drugs are most commonly used. The chart below i s not meant t o be an exhaustive list of a l l drugs injected around the world and only provides an indication of the relative popularity of two drug groups. It i s essential t o remember that increasingly, injected abuse of prescription drugs i s also becoming important.

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Opiates (mainly heroin)

South East Asia East Europe Newly Independent States Central Asia Australia South Asia Some parts of Europe

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Injecting of amphetamine type substances (ATS) i s on the increase and youth around the globe are beginning to experiment with new drugs like ketarnine. Anabok steroid abuse i s on the increase among youth i n developed countries. Other injected drugs include synthetic opiates (morphine, buprenorphine, pentazocfne, pethidine), pharmaceutical prescription drugs, notably benzodiazepines, antihistamines and painki2lers. Data on which drugs are being used and which settings they are used i n is very important. For example, high-frequency heroin users typically inject three t o four times a day with 4-6 hours between injections. On the other hand, high-frequency cocaine users will often inject i n a binge pattern, with injections every 15-20 minutes u n t i l the drug supply runs out. This binge-type use presents more opportunities for sharing injection equipment and needles. I f drug users inject alone, then sharing normally does not occur (unless someone else previously used the injection equipment). Many drug useE, however, use i n groups and work together t o buy drugs. Then they often consume together as well, dividing the doses among themselves, often using the same needles and syringes. I f the equipment i s contaminated with HIV, the virus can be rapidly spread among the entire group [ll].

Transition to injecting Some of the factors that influence the transition t o IDU are: More pleasure (tolerance development): Injecting the drug provides a “better trip”, a stronger effect, and a quicker onset of the effect. This i s especially rdevant when tolerance t a the drug begins t o develop and the effects are no longer as strong.

Most started using heroin by smoking or chasing and reported initially being repulsed at the thought of using needles. However, as their toIerance to the drug increased young people found that they were unable to suppo~Ttheir use (smoking heroin in its salt form is inefficient and yields a considerably lower recovery rate than when injected). Cunisity about the effect3 of injecting, including the “rush” also oppears to influence some Indo-Chinese young people to start injecting. Find&, peer pressure is an important factor En decisions by some Indo-Chinese young people to initiate injeaing drug use. Source: ICON, Austratia. .aoeommma.

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15

HIY preveitior among young ifljecting drug urerr

:-Curiosity: I n j e d i n g i s a new sensation and they often aspire for something new and better. Financial considerations: Injecting i s more efficient, it is cheaper than other forms since one can get more pleasure with a smaller dose. These Fs a very common reason for making the transition.

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,'. Social environment: Existing I D U i n the peer group means they are exposed t o injecting drug use. Often group pressure or group norms can be an important cause of the tansition. ***m

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"My closest friend never pressured me into taking it because he cam for me and knows how it is like to hung out and stufi, but I know he omred me that day because he suw

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Availability: The ability t o get a hold of the drug, i n comparison t o other drugs and low prices are also important factors. mmeemomoo.

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In Asia, the spread of IDU was caused by increased access due to locoffyproduced heroin after the 19605, Injecting is also associated with the quality and price of avaiIabIe heroin. When there is Q decrease in the avaihbility of "pure" heroin, or an increase in prices, the tendency is to resort tu injecting in order to produce the desired effect using srnaLLer doses [14]. .mmmm*oamo

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.'. Personal causes:

Life issues such a5 family breakdown, emotional disturbance, poverty or other personal issues can lead the drug user t o intensify his or her drug use by injecting.

*: Visibility: Injecting is less visible as it i s faster than smoking and does not leave any smelt. meeoememam m

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In a study of Indo-Chinese young people, just under harf of the interviewed youth reported that it was someone elre's idea for them to inject for the first time. About t w o thirds of partkipants had been injected by someone elre at theirfirst injection. However, there was little evidence of coembn from ethers. Nost initiations 'Ijust happened': Only a smolf number of participants stated they had planned their "first hit" and almost hay the sample reported that someone eke bad purchused the drug thefirst time that they injected. Ninety per cent had smoked heroin prior to their initiation into injem'ons. A large proportion claimed they were unwilling to return to smoking [8]. moeoeommo.

16

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Trinh’i story, Aurtralia Trinh was fifteen when she first tried heroin. Her family immigrated to Australia from Viet Nam when she was twelve-years-old. Trinh attended a local high school but was not doing well and was experiencing conflict at home. Trinh soon struck up a friendship with Lien, an Australian-born Vietnamese girl i n her class. Lien had an older boyfriend, Tuan, who was involved with a local gang that sold heroin in Cabramatta. Through lien and Tuan, Trinh began a relationship with Cuong, a young man several years older than her.

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One night Cuong was not his usuat relaxed self and insisted on calling around to Tuan’s house before dinner. She was surprised when Tuan pulled out a smatl package of white rock, broke Some off and placed it on a piece of foil and began to heat it with a lighter. Trinh was shocked but also very curious as she watched Cuong, Tuan and then Lien “‘chase the dragon”. Lien She felt happy and relaxed after smoking although she didn’t asked if she wanted a puff like the way the smoke stung the back of her throat. Even the sudden and violent retching that made her run to the bathroom had seemed somehow pleasurable and part of the experience. And the best part-none of her problems seemed to matter anymore.

..

The next time Trinh again felt btissfdly happy and relaxed, At this stage she was not aware that smoking heroin could be addictive and knewvery little about the drug. One day, Trinh woke up with Sore keg muscles and a strange keeling in her stomach. She wasn’t sure what it was-maybe she was getting the flu. She continued to smoke the drug, now and then even smoking it alone. Eventualty she complained to Cuong who immediately started screaming that her symptoms were caused by heroin withdrawal calling her a “dumb bitch” and an “addict”. Cuong dumped her. Shattered by the breakup and cut off from her regular supply Trinh sought aut Lien and Tuan who by this stage were selling heroin to “Aussies” on the streets of Cabramatta. Trinh hetped them find customers and in return they supplied her with heroin. When Lien and Tuan were arrested, Trinh started selling for herself. The first time she 5aw someone “shoot” she felt repulsed. She felt faint at the sight of the needle and the blood and swore never, ever to use a needle. However, six months later Trinh wasn’t selling enough to support her habit. Trinh knew that she wouldn’t need as much heroin to satish her cravings iF she injected but just couldn’t bring herself to be like her “customers”.

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Trhh didn’t want to inject that Rrst time. She wa5 “Ranging out” with excruciating pains in her stomach and musdes. A junkie had robbed her at knifepoint and taken all her heroin and her money. A regular Aussie customer offered to help Trinh out by buying some heroin from someone else and giving her a small shot. Trinh asked if she could smoke the heroin but Sharon refused, saying that it was a waste. Trinh finally gave in and put her arm out to be injected. Sharon administered the injection and Trinh instantly felt her pains subside, better still she actually felt pleasurably stoned for the first time in eighteen months. Afterwards Trinh felt ashamed about her first injection. She went back to smoking heroin but stilt wasn’t making enough to support her “dos”. And now she Rad a taste of what shooting felt like. Trinh knew that she would have to switch to injecting. She didn’t want to but she couldn’t afford not to and didn’t know where to go for help to quit. Not long after she started injecting regularly, relying on her customers to shoot up for her.

17

HIY prevention a m o q young hjecting drug urer!

Research conducted i n the United States has linked the transition from heroin smoking t o Fnjecting with a number of factors, including frequent and heavy drug use, polydrug use and being i n a close relationship with an injecting drug user. Social and situational factors such as unemployment, poverty, homelessness, social disruption, incarceration and the influence of social contacts have also been identified as important factors linked t o initiation of injecting [8].

Risk behaviour and consequences It is the risk behaviour o f injecting drug users that exposes them t o the danger of contracting HIV. Risk behaviour falls into two main categories: injection related risk behaviour and sexual

risk behavio ur.

Injection Yeluted fisk behaviuur It has been established that young people share injection equipment more often than older drug users and that they perceive less risk i n doing so.

The risk of HIV transmission occurs through the following activities:

.'. Direct shating/repeated

:.

use of needles and syringes for injecting.

Indirect rharing/sharing of the paraphernaba used for drug injection. This includes: *:

Sharing or using unclean water, cookers or cotton

*:

Using used syringe plungers t o stir the drug solution

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Backloading: the drug solution is transferred from one previously blood-contaminated syringe t o another. The plunger is removed from the syringe into which the drug will be transferred and the drug mixture is then squirted into the back of the syringe Front'loading: the drug solution i s transferred from one prev7ously blood-contaminated syringe t o another by removing the needle on the syringe receiving the solution, and then squirting the drug into the syringe's hub or barrel. This i s now relatively uncommon, since most insulin syringes used by IDUs do not have removable needles Squirting the drug solution from a previously blood-contaminated syringe into the drug mixing "cooker" or "spoon" and then drawing it into another syringe. Rinsing a used, bbod-contaminated syringe i n water that other IDUs also use to rinse their own syringes or t o dissolve drugs,

"Risky injecting episodes usually took place within specific contexts: late a t night or early morning with no access t o sterile syringes, when people were 'hanging out' or withdrawing from drugs or during periods of intoxication or binging, particularly when cocaine was involved , . . from the perspective o f lDUs [in Cabramatta], backloading is not a 'risk behaviour' but an efficient, equitable and even low-risk method of apportioning drug solution. As one participant noted: 'Idon't let the t i p touch anything-just i n and then out-very careful [15]."

18

F

ties i n the fact that i n the context of everyday injecting drug use, the HIV risks associated with injection may seem less immediate or important than other risks, such as overdose, vein damage or addiction. One of the difficulties

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Heroin Injecting in India: direct and indirect shoring Transitions from chasing heroin to injecting have occurred among young persons rapidly in Cbennai, India. Typicoffy, one young injector takes responsibiiity for preparing and dividing the

drug, usually heroin. The indiidual responsible for the preparation places it in the cooker (usuolly 0 spoon or an alcohol bottle cap), and then, using their syringe (the donor syringe) draws up water and discharges it into the cooker. The drug is then stirred with the syringe plunger untif it dissolves. The entire solution is then drawn through a cottonfifter ond into the donor syn'nge. The 5ame injector measures the totaf omount of the drug t o determine each injectofs share. Once portions ore calculated, the IDU preparing the drug distributes it by skirting all hut their shore of the solution back into the cooker or directly in to the other injectors' syringes. 8.*.*.*O*m

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Rapid Assessment Report, Chennai, India, 2001 Sexual risk bebaviour Sexual risk behaviour is common and difficult t o change i n IDUs. They often do not recognize the importance of safe sexual practices and can become [inks who transmit the HIV virus t o non-injecting populations. ..**'

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at her, she's healthy and wouldn't do stuff like that: But people don't realize that if you have a relationship with someone, you're deeping with all the people they slept with. If you don't use Q condom, you might get what all those other people had. " Joretta, 15 [ 171.

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Risky sexual behaviour includes:

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Vaginal and anal intercourse and oral sex without the use of a condom.

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Having multiple partners.

,'. Lack of treatment for other STIs which can increase the change of H I V transmission. High-risk injection and sexual behaviour often go hand i n hand. IDUs also often use other drugs such as alcohol, which have been related t o high-risk sexual behaviour due t o their disinhibiting effect.

19

HIV prevtntion among young injecring drug u w i

Providing sex i n exchange for money often supports drug use. I n sex work, i f i s often difficult t o negotiate safe sex practices and this i s often negkted.

.'. One-third of female drug users intetviewed i n Osh,

Kyrgyzstan, report that they are periodically or constantly engaged i n prostitution t o earn their living or t o purchase drugs. An estimated 90 per cent of these commercial sex contacts take p b c e without the use of condoms.

.'. I n Tashkent,

Uzbekistan, more than half of drug u s e d sex partners do not use drugs themselves, b u t practice unprotected sex with their I D U partners [lo].

,'. A study i n Brazil among crack users found that 60 per cent of the females worked as prostitutes t o buy drugs. The sex workers did not use condoms t o protect themselves or their customers [7].

While substantial behaviour changes occur i n relation t o injection drug use after interventions among IDUs, influencing sexual behaviour i s more difficult. The majority of drug injectors are sexually active, partner change rates are relatively high and there i s also a high degree of sexual mixing between injectors and non-injectors. Condom use i s especially uncommon with regular sexual partners. Negotiating condom use can be a difficult matter for many girls. mm****ma*.o..

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HIV infection i s the most important and the most serious blood borne pathogen acquired by young injectors. MIV enters the body, attacks, and over time destroys the body's immune system. The immunity t o diseases and viruses gets considerably weakened. HIV infection represents the presence of the virus inside the human body. Sometimes, this can go without any symptoms or signs.

*: AIDS i s the Acquired Imnmuno Deficiency Syndrome. When AIDS has developed, the body losses i t s immunity ability and many symptoms appear (infections and cancer can develop). The evolution i s progressive, and opportunistic infections eventually lead t o death, as there i s currently no known cure. However, the increasing availabi'lity of Anti Retroviral Therapy (ART) is providing hope that HIV positive people can hope t o lead fairly normal lives. It i s also worth mentioning that other injection related health consequences exist and often have more immediate effects. Some of these are listed below, however will not be explained i n more detail here.

20

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and chronic forms are common among IDUs. A vaccine exists.

*:

Hepatitis B-acute

*:

Hepatitis C--a very transmissible virus. High rates exist within IDUs, i n many places above 60 per cent of drug injectors are Hepatitis C positive. There is currently no cure for this virus.

*:

Other STIs such as gonorrhoea, syphilis and genital herpes.

Other consequences of injection drug use can be:

*: Overdose-caused by a higher dose than the body can take, this i s often fatal. Mixing drugs into "cocktails" can often be dangerous i n this sense and lead t o overdosing.

*:

Physicat damage-repeated injection can result in scarring and marks on the skin. Loss of access to superficial veins may resutt i n the use of deeper veins that can cause tissue damage. Abscesses are also a common concern for IDUS.

Specific risk groups Although youth is the target group we are concerned with i n this publication, there are many groups within "youth" which may need special consideration due t o their specific issues and problems. It is critical t o work on the best way t o reach a l l young peop!e, those in, out of school, or i n other programmes or situations. "Specific programmes may be needed t o target women IDUs (especially those who are sex workers); gay and ksbian IDUs; street youth (a large number of whom abuse substances, including injectable drugs).: and IDUs of specific ethnicities who are often marginalized such as Roma i n Eastern Europe, North Africans i n France . . . 1191" Knowing the target group you are d e a h g with and knowing which subgroups exist i n your area i s important for reaching all youth in the most appropriate manner. Some specific groups are listed below.

Young girls and sex workers There is a special need t o consider youni-women i n terms of their vulnerability and especially linked t o their access t o information [eo]. I n many countries, young women have far less knowledge about HIV then young men. Among adolescent drug using girls, sex work can rapidly become a part of life as a means of funding their drug habit. These girls are a t high risk of acquiring H I V and can serve as a transmission link of HIV t o their casual and regular sexual partners, t o their chiZdren and t o the general population through paid sex. Girls also suffer a high incidence of sexual abuse, rape and victimization. Condoms are little known or used by young women in developing countries. Their use usually depends on the cooperation of the man, and young women are often embarrassed t o suggest using a condom.

21

filV prevtntion among young injtcting drug ujen

Ferna'Les may need specialized services, such as those for pregnant or parenting adorescents. It has been shown that girls often experience more severe parental rejech'on and sexual or physical abuse than boys do. Weak family bonds are a precursor t o substance abuse i n females. Also, some studies indicate that psychiatric profiles of females show higher disturbance among a l l dimensions [21].

Horneless/s treet children The street environment places street children in especially vulnerable categories. Drug abuse behaviour i s widely prevatent. Often, drugs are used as an escape from self-degradation and misery. Services rarely understand the circumstances and specific needs of street children and their accessibility t o health care services, particularly those rdated t o drug abuse and HIV/AIDS i s severely restricted. Street populations are prone t o experimentation, and therefore are more likely t o try injection drug use. Injection may also be a demonstration of "street toughness" that presewes a person's status on the street. Besides needle sharing, unsafe sex practices under the influence of substances increases the risk of contracting 'HIV. Some findings seem t o indicate that street children are often intoxicated while having sex with opposite or same sex partners.

A study i n South Asia found that street boys become sexually active between the age of 7-9 years. Unprotected sex i s common and visits tu commercial sex workers are frequent. There i s a t o t a l lack of awareness and knowledge among street children about the risks associated with drug use/a buse and unsafe sexual practices [203.

Studies carried out by CEBRIU (Brazilian Center for Information on Psychotropic Drugs) in 1989 land 1993 revealed that up to 90 per cent of the children and adolescents who live on the streets use drugs. This figure was lowest in Rio, where rates were still above 50 per cent [ZZ].

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Immigrant groups and minon'ties Minorib groups, for example immigrants from a different culture, often have difficulty integrating into the new society and can become an isolated group that may breed drug use. I n Australia, Indo-Chinese immigrants are a specific group that needs t o be dealt with as many problems have lead them t o have high drug use rates. Evidence from several studies suggests

t h a t Indo-Chinese injecting drug users may be a t increased risk of blood-borne viral infection. As a group, they appear t o be more socially isolated, have significantly less contact with services and limited knowledge and awareness of blood-borne viruses. Recent studies of IndoChinese IDUs have found high levels of needle and syringe sharing 181.

22

Background and purpore

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To address these issues (cuftural difirences) ICUN uses discrete and sensitive bi-cultural/bi-SinguaL volunteer workers where possible and all volunteers are required t o have a flexible and nonjudgmental approach to service delivery and to utilization. Source: ICON, Australia. +mem.m*mmm

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The Roma are the most vulnerable population throughout Central and Eastern Europe. They 6ve i n slum-like houses, have high unemployment levels, poor health care and bck access t o public servkes. There is also strong discrimination against this group. Given their poverty and lack of access t o services, many are at risk of drug abuse and HIV infection. Many Roma are uninformed about the risks associated with needle sharing and unprotected sex [12]. For more information on working with youth belonging t o ethnic minorities, refer t o the Global Youth Network Project How-to guide on workfng with ethnic minorities. (http://www. unodc.org/youth net/youth net-actio n. htm 1)

Infrequent injecting drug users Infrequent injectors are those who have not yet developed fixed injection patterns, and for the most part they are ignored i n prevention and intervention efforts. However, studies of young, recent onset injectors have shown high rates of HIV infection within the first years of injecting. Random injectors may be very vulnerabte t o HIV, so it would be a valuable effort t o target this group. They are a difficult population t o target since they do not fully identify themselves as IDUs and may be particularZy afraid of the stigma of being related t o a NSEP (Needle and syringe exchange programme). They may not be as easily reached a5 IDUs through outreach programmes [23].

Young people in prison Studies i n different parts of the world have indicated that overcrowded conditions, drug abuse and limited availability of adequate services i n prisons may adversely affect the health of inmates, including through exposure t o blood-borne diseases such as HIV/AIDS.

The most difficult problem with respect t o HIV and prisons, however, i s preventing HIV transmission among inmates while they are i n the facility. Qf course, the activities that transmit HIV, i.e. unprotected sexual intercourse and the sharing of drug injection equipment, are officially banned i n prisons. Nonetheless, even though it is unrealistic to expect prisons,

23

HIV preverttioa among young injecting drug wri

particularly those t h a t are understaffed and overcrowded and that house large numbers of persons with drug abuse problems, t o be completely free of these activities, it i s extremely embarrassing for prison officials t o publicly admit that these activities do i n fact occur. Such denial has been one of the reasons why the distribution of condoms, bleach and sterile injection equipment has been limited within prisons [25]. For young people i n prison, there are additional risks considering that they are often physically weaker than other inmates are (youth are not always incarcerated separately from adults) and may be forced t o take part i n drug related or sexually related activities.

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Alfreda, an 18-year-old Hispanic female, contracted AIDS while in a youth lock-up in her teens. She is one of many youths who are left onfy minimoily supervised during the night shfl in many lock-ups. She descn‘bes the sexual environment as one of experimentation and curiosity. “We did it to fight the boredom, to give us something to do, ‘‘ she describes, Aifreda returned from the lockup tu her neighbourhood, where the same problems, (that is, 0 lack of supervision and knowledge) existed, not onb with the psychological scars of incarceration, but also with a physical reminder of her unsafe sexual exploits while in the lack-up 1261. mO**O*.**.e

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Prison populations can not be forgotten simply because they are closed off from society for a certain time. Remember-prison inmates come from the community and will most likely also return t o the community.

Guy and lesbian youth Many studies have concluded that the frequency and variety of drugs used by gay men i s greater than that of heterosexual men. For instance, 38.5 per cent of gay, lesbian, bisexual and transgender youth admitted heavy drug use compared t o only 22.5 per cent of their heterosexual peers i n a study i n the United States [27]. The explanation for these findings usually involves the social and emotional isolation. Up t o 80 per cent of gay, lesbian, bisexual and transgender youth report feeling severely isolated socially and emotionally [28].Substance abuse often results from an attempt t o manage stigma and shame or t o deny their own feelings. It i s important not t o assume that homosexuality causes drug or alcohol abuse. When gays, lesbians and bisexuals internalize society’s homophobic attitudes and beliefs, the results can

be devastating. Society’s hatred becomes self-hatred. As a minority group, gays, lesbians and bisexuals are victims of systemic and ongoing oppression. It can lead t o feelings of alienation, despair, low self-esteem, self-destructive behaviour, and substance abuse (flicoloff and Stiglitz, 1987). Some gays, lesbians and bisexuals resort t o substances a5 a means t o numb the feelings of being different, t o relieve emotional pain or t o reduce inhibitions about their sexual feelings. Substance abuse often begins i n early adolescence when youth first begin t o struggle with their sexual orientation. When surrounded by messages telling you are wrong and sick for who you are, eventually you begin t o believe it. Having t o hide your identiw and deal with homophobic

24

camrnents and attitudes-often

made by unknowing friends and family-can have a profound effect on you. I n response t o this overwhelming oppression and homophobia, many lesbians, gay men and bisexuals use alcohol and drugs t o cope.

A subgroup within this group, which has been identified as being a t high risk of HIV infection, i s young men who have sex with men (YMSM). Among males ages 13 t o 19, 41 per cent of AIDS cases and 5 2 per cent of HIV cases reported t o the Centers for Disease Control and Prevention (CDC) i n 1997 were among YMSM and YMSM injecting drug users [29].

I n a 1996 study, 38 per cent of YMSM reported having unprotected anal sex, and 27 per cent reperted having unprotected receptive anal sex [3Q].

One i n four YMSM i s forced t o leave home because of his sexual orientation, up t o half o f these youth resort t o prostitution t o support themselves-greatly increasing their risk for unprotected sex [31]. Perceived invulnelability i s characteristic of youth but i s especially problematic for YMSM, Considering their risk for HIV and their lower rates of safer sex as compared to older gay males

Youth Living with HIV/AIDS are a group with very specific needs, which are different from other groups, considering this is a group who has already contracted the HIV virus. This group needs efforts in treatment and care and i n reducing stigma related to PLWHA (People Living with HIV/ AIDS). Issues of this group are discussed in chapter 2, under "HIV positive youth".

25

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T IE P fly lTEP - how to build a programme Prevention of the spread of H I V among IDUs uses various strategies. The most recommended way t o go about prevention is t o provide a comprehensive package of care for injecting drug users. This section should help you t o build up your programme by following the ideas we have brought together here. Remember-this guide is not all encompassing, there is always more information being released and other sources that can help you with specific aspects of your work. This guide should help you get started, but it will not be your ending point! A comprehensive package [32] should aim t o include:

*: Provision of HIV/AIDS information and education: Access t o basic services and primary health care;

.’. Life skills training and peer education;

:.

Condom distribution;

.’. Access to clean needles and syringes and possibly bleach materials; .’. Voluntary and confidential HIV testing and counselling; .’. Referral for a variety of treatment options. 27

H Y I prevention among young injccring drug uien

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A good guideline to keep in mind when considering how to go about HIV prevention is a hierarchy of prevention, which can belp to set moll, achievable steps which can be reached progresIivefy [19]. In a review paper from U N I E t this typical hierarchy appears:

"The most effective way to prevent transmission is to never start or to stop using drugs. *:

If this overall goal is not achieved for a specific individual

the drug user should be encouraged to use drugs in any wuy except injecting: Vyou do not inject, you cannot catch infections through sharing drug preparation or inje&-on equipment.

*: Ijthis goal is not achieved, the drug user should be encouraged to inject with new/steriLe injecting equipment every time and to not share preparation equipment.

*: If this god is not achieved, the drug user should be encouraged to re-use his/her awn injectng/ preparation equipment every time: if you re-me your own equipment every time, you cannot catch viral infections such as HIV (unless someone else has used your equipment without yo UT know ledge). I f this goal is not achieved, the drug user should be encouraged to clean needfes/syringes and other equipment by an approved method. There is some risk of HIV transmission after equipment cleaning, but cleaning in an approved manner will reduce the likefihood of

transrniss io n. The hierurchy provides smull steps which drug users can be encouraged to take to reduce and hopefully eliminate HIV risk behwiours."

Know the target group From chapter 1 you can probably understand that young people have very special issues and needs that should be considered when wanting t o build an HIY/AIDS prevention programme.

Remember that due t o social isolation and stigmatization, as well as for many other reasons, young IDUs will usually not come forward looking for information or help. For this reason, we need t o go out t o where the youth are; a process called outreach, which will be explained below. However, t o do this, the first thing we need t o know i s who our target group is. Some of the basic things t h a t you should find out before you start are:

,'. The demographics of your target group: characteristics such as age range, gender, social status (are users mainly street youth or students), educational level. *:

28

The extent t o which they inject: compared t o the use of other types of drug administration.

I

Remember: HIV prevention should begin immediately, even if there haven't been many cases of HIV in the area, The spreod of HIV among injectors can occur rapidly-more rupidfy than the time it would take to set up a programme in response. Injecting behaviour and patterns: What drugs they tend t o inject, when and how many times they usually inject, the places where they usually "hang out". Remember that injecting on the street or public places often escalates the risk. Who they inject with i s also relevant: IDUs who use drug with strangers (SW for example) are a t increased risk. Also, using with many people and rapid partner changes can spread the HIV infection rapidly.

If there is a leader i n charge of their network: For example, if adults are those i n charge, who bring youth in, then a different approach i s needed than if Ks a network of youth only-in which you should use peers t o reach them. Their sexual behaviour: How much risky behaviour i s there? Who do they have sex withregular partners or CSW or others? Do they use condoms? The HIV/AIDS (and VI)situation i n this population: How many people have these illnesses as well as whether support and health services exist i n the area and the extent t o which IDUs are aware of them. It may not be so easy t o gather a l l this information. Do not let lack of information stop you

from getting staked, however keep i n mind that the more you know, the more chances you wilt have t o reach your target group. Also remember you can always collect more information once you have got started. So, how do you get this information [33]?

*: Young people involved in your project can tel! you about issues that are important t o them and trend that they know about. They can also help you gather information from the target group.

.'. Gathering information

djrectty from the target group i s useful; this may be done i n informal studies, and interviews i n the field.

I

Remember: IDUz may be suspicious of you and not want to talk to you about their adivities. I t heips tu make contact with one or two people and through them reach others. IDUs muy not want to admit to shon'ng needle and syringes. They may understate their risk behawours. ....*'*'**ma*.

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: "Nobody wants to admit that they do it [share], How stupid do yuu look? They know and

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we know that pdre not supposed to share anything, not w e d a spoon. So you feel iike *a you've done something wrung. I guess you have [done something wrong] but you don't ;w m t to udmit it cause you know it's wrong too." Alex E151 *

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Local authorities on AIDS and health as well as universities may have information that you

can use.

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29

HIY prevention among young hjecting drug uvri

*: Hospitals and emergency rooms.

*: Local researchers i n the field can help YOU with information or references. *: Newspapers and magazines sometimes have articles on HIVJAIDS and other important issues.

:.

NGOs and other groups already working with the target group or with other groups i n the area.

2. The p o k e and pn'sons as well as courts. This is clearly not an all-inclusive list, and it would be dfffn'cult t o try and provide such a list, considering different countries and groups can lead t o very different conditions, requiring the knowledge of different information. Foor ideas and tips on getting the information you need, refer t o the Global Youth Network pubtication: A participatory handbookfor youth drug abuse prevention programmes: A guide fur development and improvement. ( http ://www. unodc .org /yo ut hnet/y o u th net-a ctio n .htrn I) For more detailed information on How to conduct a rapid assessment of the situation, particularly

with regard to injecting drug users, please see http://www.who.i mt/docstore/hb/Core/Index. html, a technical guide for Rapid Assessment and Response t o HIVIAIDS.

Staff Who are the appropriate people to work in HIV prevention projects? What kind of characteristics should they have? Staff who are going t o work i n a prevention programme with young IDUs need t o have or learn certain Characteristics . .

.

*: They should be open, free of prejudices and stereotypes, and have a non-judgmental position towards drug use. They should be caring, understanding and sensitive. They need to have respect for IDUs, and for their confidentiality.

*: They should have a certain level of knowledge on safe injecting and safe sexual behaviour

:.

as well as knowledge on HIV/AIDS.

They should not use technical language, but shou'ld be able t o reach IDUs on their awn level, t o work ''with them" rather than "for them". Outreach workers Will need t o be available a t normal working hours as well a5 unconventional hours, a t which the programme should aim t o work as well.

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Since outreach workers should be reachable 24 h u m u dag mobile phones can help a lot In one m e , a project in Brazil was able to negotiate a discount rate with the mobile phone company once they explained that the phones were being used f o r outreoch work.

*: They should have dedication and commitment t o the cause.

:.

30

There should ideally be outreach workers of both sexes, as some males or females may feel more comfortable talking t o someone of the same sex.

F

Drug Users as well as non-users can be hired as staff, and each group has its advantages and disadvantages. Using peers t o talk t o young people i s an element that is considered important in developing prevention programmes. Young people axe not likely t o seek advice from teachers and adults for various reasons, such as finding them untrustwofihy. However, youth tend t o listen t o the experience and the advice of their peers because they present information about drugs Without preaching or judging behaviour. For a more i n depth discussion of peer t o peer strategies and using peer educators, see the Global Youth Network Project How-to guide on using peer t o peer strategies i n drug prevention. (http://www. u nodc.org/yo uthnet/yout hnet-action, htm 1)

Current users as staff

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Using current users has the advantage of them knowing the language of the IDUs, they are accepted by the drug users and know their needs. Peer workers often have personal experience of IDU and can be recruited through NSEP or youth organisations or outreach workers [23].

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''[How do you reach drug users?] Ey wonking with other drug users. I t is fundamental to have drug users us active participants in harm reduction programmes. I n Brazil, of the over ; 1000 people who work in harm reduction, 70 per cent are drug users, I am convinced that this is the key tu the pmgrammdsuccesses." Domiciano Siqueira, Co-ordinator of the Harm Reduction Association of Brazil [4].; 4.**..* ***. .** o * * * * ~ * ~ * ~ * * ~ ~ . . o ~ o . a ~ n m ~ ~ ~ ~ ~ * ' ~ * * * * ~

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Using peer educators does not only have advantages for reaching the IDUs (by increasing trust and cxedibiility and having an equal level of communication), but is also can help the outreach workers themselves, by giving them knowledge and skills and allowing them t o have a meaningful function i n the programme.

However it i s worth remembering t h a t current users may not have high credibility among peers and may not be reliable.

31

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HtV prevention among young injectJng drug ureri

There may be other difficulties related t o using IOUs as staff. I n some instances, t o some people, it may send out a mixed message if a user i s used as a model t o give o u t information about drug use, getting o f f drugs and preventing disease transmission. Some youth may also prefer t o be i n touch with someone who has either sucsessfulty stopped using drugs or who does not use drugs, t o get support i n his or her attempts t o stop using drugs. Also, there may be some legal issues related t o drug users, which have t o be considered before starting.

Ex-users QS staff Ex-users have many of the advantages of current users. They have experience with IDU and may have increased credibility among peers since they have succeeded i n becoming clean. However, getting involved i n such a programme may be d i f i c u t t for them and could lead t o relapse.

: Telling the story of his drug use gives Ofego the strength to be Q ~ Ioutreach worker. ; "I began injecting drug when I was 18 years old, but i t has been over Q year now that I

..

.* huve not inj&ed, it no ionger seems like a good idea to me Many times I wake up and I go through the entire day With a syringe on my mind" 'Diego, Intercambios, Argentina. '*m.mm***o.......

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Although it may be difficult for this group t o establish a relationship with the IDUS, and although they do not have full knowledge or drug use, there are various advantages of using non-users i n the programme. These may be trained professionals who have a l o t of knowledge on H I V and AIDS and this may stimulate discussion, i n which the user can talk about his experiences while the staff can bring a more theoretical view. IDUs may want t o speak t o non-users about ceasing drug use, and the staff may be their first contact for social re-integration.

Training A l l staff should have basic training so that they are knowledgeable about risk behaviour and risk reduction (both injecting and sexual risks) related t o HIV transmission. Staff should be aware of the aims of their interventions and be clear about what their role i s and what i s expected of them. Although peer educators have contact with the target group, they need more skills for o u t reach work.

S t a f f training should specifically emphasise the reduction or elimination of prejudices and stigma, examining ath'tudes towards drug injecting and HZVJAIDS. Confidentiality and other important aspects of work, such a5 respect and credibility should be covered during training.

32

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IT€P BY IT€P - how to build a programme

Planning and involving youth Involving youth i n projects relating t o youth is a key aspect of making a programme aimed at youth work. Youth know what they like, what kind of information or styles will appeal t o them and what they w i l l or w i l l not find interesting. Youth can be involved i n a l l aspects of the programme, from planning and developing the programme t o implementation. "Effectiveness of programmes for young people appears t o be enhanced by employment ef peer staff (of a similar age or slightly older than the target group) and youth-friendliness o f I E C materials, premises and staff this has included use of youth culture symbols i n IEC materials and as posters i n premises, involvement of young IDUs i n designing and producing IEC materials and i n planning and implementing programmes, and staff training t o understand the needs and culture of young IDUs [19]."

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YouthCU is a "youth-dn'ven" agency. This mean5 that YoutbCU works to ensure that the voices of people between the ages of 15 and 29, inficted with and/or affected by HIVAIDS, steer the direction of the organization. At YouthCO, youth are oficered the opportunity to voice their opinions on ogenLy priorities, policies, and programming needs. Youth work with each other to identify areas of advocacy and suppurl, and t o come up with new and exciting ways to educate their peers. Youth ore involved in all areas of ogency decision-making and programme implementationbe that within our board of directors, our Stafi our volunteer programmes, and/or within our Membersh@services.

Source: YouthCO, Canada.

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Youth involvement i n the organization of these schemes is essential. I n Bulgaria, the Touching Reality project trained young people age 14-19. NGOs provided basic administrative support and preliminary training but otherwise there was a 100 per cent youth involvement policy. A mid-term evaluation showed it is often dificult for NGO's t o let go and l e t young people express their own ideas i n their own language. On the other hand, young people were shown t o lack certain skills such as reporting and compiling financial statements and accounts. These essential skills must be included i n the training programme if young people are t o take complete responsibility for the project 1231. When youth are involved in planning and implementing a programme, they feel a sense of ownership and responsibility towards the project. Not only i s their participation beneficial for the project, as they are good sources of information, ideas and feedback, but it is also beneficial for them. Youth can often gain a l o t of experience and being involved i n a prevention project can help them channel their interests i n a useful and safe way,' especially youth t h a t are part of the target group.

33

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Youth cam be involved a t various levels:

.'. I n consultations and focus group discussions t o get ideas and collect information: .'. Active involvement i n implementing projects, (for example being trained t o be peer educators or being involved i n NSEP);

.'. Involvement i n initiating,

designing, and planning the project.

Youth may look and speak differently than the other staff, but this shouldn't be an obstacle. There i s a l o t t o 'be learnt from youth, especially those t h a t are part of the target group, and your project needs their involvement for success.

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Remember: moke sure the youth are clear about their role and their responsibilities and trufy involve them and make use of their ideas--let them know that their ideas are important and will be taken seriously and used in the projecf.

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The Indo-Chinese Outreoch Hetwork in Australia is a street based outreach programme engaging young Indo-Chinese drug users. As well as needLe and syringe exchange and condom distribution, education and referrah, and other activities, they also have community development projects, which have included a photo-narrative exhibition and a weekly young women's group: tabragirlz. Young people ore invoLved in all aspects of the programme, from input in weekfy meetings to participahig in peer educotion and harm minimization training programmes, community development and research activities. Peer educators are drawn from the target group.

The Cubrqirlz project incorporated deveIopmenta1 writing and peer based education as part of the constmction of a website on drug-related hams specifcal& targeting people from Asian backgrounds. (http://horne. iprimus. corn. au/avwwa/index*arneset. htm).

"The development and administration of the project certainly was not predictabie or smooth, but nor were the Lives of the participants. Flexibility was crucial. We learned to accept that peopIe wiff come ond go and that "our" expectations are not always the same as partiopant's expectations. If we are to deliver the best possible outcomes f i r ethnic Vietnamese heroin users then they need to feel that projects belong to them and that they have Q say in their direction 1341. emmammeom.

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Community Support from 'Local authorities and communities has shown t o be of v i t a l importance. Programmes should be free from p o k e harassment and linked t o other services. Police activity attempting t o prevent drug selling and buying as well a5 possession i s often devastating t o programmes. For example an Australian programme reported 40 per cent less contact with clients after police operations targeted IDUs i n the area and around the NSEP site [lq].

Look a t your aims and try t o consider which groups or people could help you or could create resistance t o your project. For example, police and law enforcement could be a barrier t o

34

!l€f BY SKP - how ro hilda programme

reaching young people. Contact these authorities and talk t o them about your project. Offer t o run a course on HIV/AIDS education for police for example. Try t o come t o an agreement on how t o encourage the project.

A t Chennai, a law-enforcement official serves as an advisory board member. By liaisoning with the law enforcement officials it is possible t o carry out the activities with the young drug users i n the community. Several workshops on HIV/Drug abuse for the police officiak have been conducted. . * * b * * m e ~ m + a b m m

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"The police are supporting our uctjyitia as follows: agm'mg on the component of syringe ; exchange, teaching AA [Adolescent Association] staff how to work with injecting drug users, *- allowing AA to keep the confidentiality of drug users, collaborating in developing education materials." AdoEescent Association, Romania.

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Not only law enforcement authorities, but aZso government and authorities as well as the general population may have reservations concerning work with IDUs. Stigma and stereotypes can lead t o negative reactions. It is a good idea t o build partnerships with the community, t o meet with and t o involve the community a t large when possible. The aims of your programme should be clearly communicated t o the community and efforts should be made t o allay any specific fears the community may have about your work. It should be explained t o the community that your group is not providing drugs or encouraging people t o take drugs. Rather, the health benefits of your work should be pointed out.

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"While prevention pt-ogrammes consisting of AIDS education, condom promotion, needle exchange and drug treatment have proven effective, strong political determination is now needed to apply energetic prevention measures and reach out to marginalized people and their partners [14]."

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"Since we are dealing with an excluded and excluding client group, we have difficulties in m convincing the population of the importance of the work, and the need to see users firstLy * a5 citizens and not pninariIy as usm." Projeto de Reducao de Danos de ItajaT, *

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Santa Catarina, Brasil. f

The communiQ may be afraid that their children will come into contact with users or that needles wjtl be left lying around i n their neighbourhood for example. If you are creating a drop i n centre, for example, you may want t o enter into a diatogue with the community explaining t o them that

35

I

HIV prevention among young injelting drug urerr

while the number of drug users "hanging around" their area may increase, considering their concerns and dealing with them adequately.

". . . There were negative reactions,

because people stigmatize drug users. People think that drug users are delinquents or sick peopk who we must cure, but neither of these ideas is true. There are an enormous number of prejudices against users of illegal drugs and the stereotypes tome from all of the institutions of modern society: t o the religious, using drugs i s a sin, t o the courts it is a crime, and t o the health care professionals it is an illness. Another misconception that some people have is that by handing out injecting equipment, we encourage drug use. We are not drug traffickers, we are public health agents. I hand out needles because I hope that the person who i s injecting does not contract HIV or Hepatitis and that he can be more happy given the choices that he has already made. We have a responsibility t o protect Eves." Domiciano Siqueira, Co-ordinator of the Harm Reduction Association of Brazil (41. The community can be involved i n activities of your group such as festivals or activities for world AIDS day. Encouraging participation of community leaders and stakeholders i n events can enhance support. Families of IQUs are also important factors t o consider. Often, since IDUs w i l l be contacted on the street through outreach, it will be difficult t o have contact t o their families, considering that their confidentiality is a high priority for the programme. However, when possible, involving the family is a positive step, considering that families often have many misconceptions about HIVJAIDS and drug use. They may need information or also referrals t o help services and more. They can help youth t o learn about safe practices and can help them through withdrawal and treatment if they have knowledge.

Parents and families, ifprovided with enough knowledge, could help other families t o understand drug use and the needs of their children.

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"Parents talk to parents, 'Oh my daughter use too much, my daughter use this much: The parent could educate other parent Iike the kid being the peer educator [13]? Thuy

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Youth need and want support from the parents, however this i s often not given when the parents find out about their drug use.

36

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STP BY SKP - how to build a programme

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"My fPmily was rike any famity we had our ups and downs. Using changed a lot of things. The relation with family got bad because of my drug use. I was hardly home to spend happy times with them. But when I'm home we usually fight or argue with my parents ur sister

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and brother. We didn't get on at all maybe because the drug change me [13]."

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: ''Before I used heroin things were ok for me at home Morn and Dad love me. When they find

; aut I'm using Dad stopped talking to me and Mom don't

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Do not forget that i n some cases, drug use comes from the home, meaning the parents also use or abuse drugs, and may have contributed t o the initiation of drug use. I n other cases, problems i n the home may have led the youth t o resort t o drug abuse. I n any case, when possible, f a d i e s slhoukl be brought i n t o programme activities.

Establishing contact I n general, as we explained above, IDUs will not come tooking for you, so after you have made some contacts, you have t o go t o where they are. When you have contact with some peopte, they can introduce you to others.

Go where they are: this will often be mainly the street, however, other outreach sites can include any place that allows contact Such as discos, patty's, bars etc.

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"I work us a horm reduction activist and I do it wfthjoy. I go to the houses of the users, I enter the cuevas-tbe pfaca where users gather to inject themselves r go and I distribute materials in the street, in an alley. I see that I am doing good Juan, Intercambias, Argentina (41.

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A more friendly approach starts with Location and accessibility. Small centres i n popular youth districts, with late opening hours are most accessible t o youth. A t this point it i s important t o use the Language t h a t the target group uses and have your information i n a form they will be able t o relate fo-don't use technical language. Using the peer network i s important here t o make proper contact and t o know how t o access and communicate with the group. Having appropriate staff (a5 mentioned above) can make the first contact easier. Making contact i s a process of building trust, and you need t o show you are worthy of their trust, allowing them time t o observe your group and see if they can open up to you. You should be responding t o their needs, and should adapt accordingly.

37

HEY prevention among young injecting drug wri

Remember: IDUs may be suspinbus of you atfirst They ore accustomed to law enforcement offiCiarS and other authorities why can make their IVe dificuit, so they may nut want to associate or open up ut first. It takes time t o build trust.

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What t o provide and how Groups still not injecting move on t o injecting after a period of inhaling or snorting the drugs or other forms of non-injecting drug use. Various factors, as mentioned i n section one, contribute t o the transition t o injecting. However, this transition is not inevitable; many drug using groups I n most cases, individuals

remain i n non-injecting subcultures and never make the transition t o injection. For the non-injecting groups there are various prevention efforts which are important t o emphasize:

*: Efforts can be made t o reduce drug use and encourage abstinence i f possible.

:.

Efforts can also be made t o prevent the transition t o injection, giving information and life skills as well as alternative activities as preventing measures.

*: After the first injection, there i s generally a rapid progression t o injection as the preferred route of administration. So infrequent injectors are an unstable group and interventions t o not have much space or time t o be effective [23].

.'. Even i n non-injecting

drug users, HIV i s a risk, potentially spread through unprotected sexual contact with other drug users who may be injecting or commercial sex workers or other sexual partners who have had sexual contact with HIV positive people.

For drug prevention i n general, it i s often profitable t o use different tools, such as sports or

drama, t o creatively engage youth i n prevention activities. More information on these methods can be found i n the Global Youth Network Project How-to guides: "Sport-using sport for drug abuse prevention", and "Performance-using performance for substance abuse prevention". (http://www,unodc.org/youthnet/youthnet-action. html)

For preventing the transition t o *:

IDU, some points are worth

Provide adequate information through education. Have intensive and consistent prevention messages.

,'. Develop decision-making skills and capacity.

38

keeping i n mind:

F

STEP Y t STfP - how to hE i da programme

,'. Use alternative activities, challenges, concerts and music. Do not say a b b n k "no" without explaining further.

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Do not stigmatize abuse. *: Try t o comprehend the users and the pressures they may face pushing them towards riskier modes of intake.

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To take htQaccount the fact that the community of drug users are very closed, the first thing we did was to contact them, to gain their trust and to keep in touch with them. To enter the community of drug users we hired young former drug users working as social e Outreach workm. I n the first year we mode contan with the drug use& in an apartment, r the accommodation place of drug users or at sociul workefs homes. There we:distributed information muterials on drug use and safe sex and did syringe distribution and needle exchange. The second year our aCtiVities were enlarged: 0 cuntact centre for drug users w s a organized where drug users have meetings support groups and individual counselling, and which is a h a fixed syringe exchange place. Outreuch w m extended to the beach uf the * Black Sea and three other locations, nte target population was ~ I s aextended to prostitutes m + who QW in t w c h with drug users.# Adolescent Association, Romania.

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:Steps to a positive direb'on-Initiative **

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The basic idea behind outreach i s that education and services need t o be taken t o young people in their milieu, rather than waiting for youth t o seek out services. As mentioned before, for various reasons, young IDUs are not Likely t o seek help on their own, so outreach i s a major aspect of work with young injecting drug users. Outreach usually occurs directly i n places where the target group spends time-often

the street.

Outreach aims t o reach young people who are not reached by existing health or information

services. It i s important i n reaching o u t of school youth and street youth and experience shows t h a t it i s not difficult t o do, not expensive and a good way t o reach those living in vulnerable conditions.

Outreach workers make face t o face contact with the target group, learn about them and their needs and develop services appropriate t o these needs. This needs time, as the first thing that

39

3

HIY preveition among young kjeaing dnrg UI~M

P

needs t o be done is build trust. Outreach workers should listen and observe the youth, and not push them t o do anything they do not want. Users should not feel pressured t o change behaviours, rather they should learn about reducing risky behaviour i n a respectful, trustful way. As time passes and trust begins t o form, more activities can be suggested and added. While some types of outreach initiatives chose t o focus on information provision others include provision of direct services t o IDUs. Information only outreach programmes are few and far between and even where they do exist, they aim to provide effective referral services to service providers. I n one sense, outreach is merely a vehicle for provision of whatever i s needed by a target audience. I n settings that are hampered by legal restrictions on service provision or where social stigma i s particularly high, information provisfon may be the only effective way of intervening immediately. Outreach i s widely considered the best way t o reach young (and old) injectors. I n Chicago, a large outreach programme achieved a reduction i n risky behaviours from 100 per cent t o 14 per cent over four years and the rate of HIV infection fell from 5 per cent t o 1 per cent per semester by the last six months of the study [19]. Targeting outreach with young injectors who are not i n touch with regular services i s critical. Community based outreach involves: =:

Identifying and making contact with target populations i n their natural environments;

*: Estabkhing rapport with the target populations: Enlisting commitment t o behaviour change; Providing information about unsafe as well as risk behaviours;

.'. Strategies

t o reduce risk behaviours;

*: Promotion of safe behaviours. Remember: confidentiality is essential, especially for building trust. Drug use is illegal, so youth will likely be suspicious of workers reporting them to the police or other authorities. It is important for youth to feel comfortable with the outreach workers. .eP.rn**.rn*rn*rn.rnmmo.,emea.a.rne+e *. o e . a . m e o * . a r n m . a . . . a ~ * " . Some more points to keep in mind 1351 . . Be careful-the drug scene can be violent. Be clearmake sure they know who you are and whom you are afifiated to. Alro be sure that they know who you ore not afjcriiated t o (far exompie the police). Develop a pattern--try to have a fixed day and time that you go to a certain area so people know when to expectyou.

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Peer outreach is a more specific form of outreach that uses peers t o reach out t o the target group and through this can be more acceptable t o youth. It i s also usually a less expensive form. Peers may be especially appropriate for outreach work, as they will better understand the

40

target group's ways and will possibly be able t o communicate with them with more ease. Although they may not have a background i n education or hetping professions, they have life experience and commitment and can develop good relationships with the young people. The advantages of peer t o peer work include the fact that peers often influence young people. Peer pressure i s often considered negative, but i n this case peer influence can be used i n a positive way. Young people also prefer t~ lean about sensitive issues from their peers. For example, many young peopZe consider that it i s difficult t o talk t o adults about sex. Adults also have difficulties talking t o young people openly about this.

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"It's p o d because when I was in gaol and these giris were saying shoot up I had a friend who was unsure about it. She asking me do you reckon I should shoot too

.- .

She goes, "it's Kate's fit (syringe/injecting kit), and you know she d o e d t let anyone else use it: She was just unsure about shooting up and I said, even if you clean the fit with bleach it3 not ok. I drew her like a picture of the fit which got grooves in it. That's where

the blood stays, 50 when you' wash it the bleach doesdt actually wash out the blood in the grooves. I said that's how you catch HIV or your AIDS, or your Hep C. She was thinking oh, wow, you've actually learned something new, and Ifound it reaily good. On the street there's people that ask me and I tell them. Lots of people didn't actually know that by using swubs' spoons, waters that un old fit hud touched, you could actually catch the Virus. They're like, wow, I didn't know that and they are more uware now." Phuong [13].

4

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I n peer education, active IDUs are trained t o educate other IDUs about HIV risks, safer injecting and safe sex. The New South Wales (Austratia) department of health defines peer education as "a set of specific education strategies devised and implemented by members of a subculture, community or group of people for their peers. Where the desired outcomes i s that peer support

and the culture of the target group i s utilized t o effect and sustain a change i n behaviour [8]," The idea i s t h a t IDUs may be distrustful of messages corning from mainstream organizations. Peer education provides an effective and low-cost way t o reach these groups. It uses already existing paths of communication t o disseminate information and skills. Peer network interventions reduce the risk behaviours by developing a culture i n which IDUs and their peers support each other i n risk-reduction efforts. The major goal i s t o devetop a self-maintaining culture i n which IDUs and their friends can actively discourage each other from engaging i n behaviours such as syringe sharing or sharing other paraphernalia. For more information on peer t o peer work, refer t o the Global Youth Network Project How-to guide on using peer t o peer strategies for prevention. (http://www.unodzorg/youthnet/youthnet-action. html)

41

HZV prevention among young injecring drug uren

Don't forget: outreach should be part of a more comprehensive approach. After relationships are established, activities should be widened and other strategies should be used. (These ore rn

discussed below) . Another point: outreach workers may be exposed to a signifcont amount of psychological stress. They may witness IDU deoths or have frustrations due to relupses into sharing. Psychological counselling f o r outreach workers or supervision with o muitidisdphmy team as well as having debsiefing sessions is a good idea to avoid problems. Also, having a reward system, not in economic terns, but in an alternative woy, may be a good ideo to keep €he r n o t i v a h going.

Information Young people need t o know the facts about HIV/AIDS and about drug use. They need t o know how HIV can be transmitted and what risk behaviour is. They also need t o know how t o reduce their risk behaviour and how t o protect themselves from infection. Information can include:

.'. What HIVIAIDS is. .'. HOW a person can get HIVJAIDS. *: How a person can avoid getting HIV, including information about injecting paraphernalia and the importance of dean equipment.

.'. How t o use a condom

and other safer sex approaches including abstinence and monogamy.

*: What services or treatment centres are available t o them, (detailed information on voluntary counselling and testing and STI treatment), how t o reach them and other information related t o partner services. For this, it i s vital that the information you provide is: Easy to understand: Make your brochures and propaganda i n the language of use, including slang and street terms.

Attractive: Make the information look interesting t o them-using appeal t o their interests. Use slogans and catchy phrases.

pictures or drawings, which

Short: Keep information t o the point and accurate. loo much information will not be read.

It i s often profitable t o use educational materials designed by youngsters or former or current drug users. They can help t o make the information more interesting for them.

Different countries developed different styles and messages t o adapt t o the lifestyle and preferences of their target group.

42

/I YOUTH CO POSTCARDS

BRAZIL BROCHURE

"Space Commando... with heat seeking missile ...

"Aids e usuarios de drogas injetaveis"

ARGENTINA STICKERS "Yo hago la mia

COR

forro"

ALways protects his missile"

ii

Needle and Syn'nge exchange programmes After making some contact and building a rebtionship, giving information i s not enough. IDUs need concrete senn'ces t h a t can help them reduce their risk behaviours. It i s not realistic t o assume that if they know about the risks of needle sharing, they w i l l immediateLy go and get themselves their own clean syringes. One of the factors associated with the sharing of injection equipment i s the low availability of sterile needles and syringes. Often they do not have money or other means t o get sterile equipment and would not go t o great lengths t o get it. Advice will often be ineffective unless it i s supported by the availabikity of sterile equipment. In light of this, the development of needle and syringe exchange programmes i s particularly appropriate for this target group. The purpose of the Needle Exchange Programmes is:

To distribute sterile injecting equipment to IDUs: and remove used and potentially contaminated injecting equipment horn circulation, thereby removing the possibitity of further use. This aims t o reduce HIV transmission through reducing sharing of equipment.

To distribute other equipment used i n injecting (such as cookers/spoons, alcohol swabs, cotton, steriZe water), and other materials such as condoms. To provide a point of contact with IDUs for dissemination of IEC materials about safer injecting and about prevention o f sexual transmission.

To potentialty become a contact and referral point for counselling, primary health care, welfare and other services, and drug treatment service. Equipment offered a t the needle exchange sites can include: Needles and syringes i n varying barrel sizes and needle gauges according t o needs of client

*: Sterile water m:

3

Alcohol swabs Condoms Disposal containers (puncture resistant, sealable)

.'. Risk reduction educational brochures (unsafe sex, unsafe drug use) Programmes can focus on distribution of needles and syringes or alternatively on exchange. I n exchange, new needles are given i n exchange for used ones-thus ensuring safe disposal of used equipment. I n some cases, clients of the programme can collect sterile equipment not only for

43

HI! prevention among young injerting drug tlieri

e

themselves but ako far distribution t o other IDUs-in effect, they are then working as unpaid peer outreach workers. The rationale for this style of programme delivery i s that it increases efficiency, with less pressure on programme staff, and increases reach to populations o f IDUs who would not otherwise attend the needle-syringe programme. m.....

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: "Huving syringes avaihble insures that drug users use clean needles and do not look for used ones

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to use drugs." Fablo Cymerman, coordinator of the Argentinean Harm Reduction Network,

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Reviews of the effectiveness of syringe and needle exchange programme have shown reductions

in needle risk behaviours and HIV transmission and no evidence of increase i n injecting drug use or other public health dangers in the communities served. Programmes have also been shown t o sene a5 points of contact between IDUs and service providers including treatment programmes. The benefits of NSEP are increased if they include AIDS education, counselling and referrals t o treatment 1321. The following factors are important t o consider when planning a NSEP:

*:

Location (for example drop i n centres, mobile vans, hospital wards, outreach sites.) The NSEP should access the hidden populations of young injectors and the services should be delivered as close as possible t o where drug injectors live or hang out.

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Hours of operation (projects should aim t o ensure easy and free 24-hour access t o sterile injecting equipment). m ~ * * * * a m e

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"For me, preventing harm to mperf means using new needles and never sharing spoons, waters or swubs. But you can't always be sujk. Sometimes the chemist dose early or there's ** nowhere to get new equipment lute ut night. Or it might be P public holidays and there's I I nowhere to get equipment [23]." 0

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.". Staffing (remember the advantages for peers being invohed). The needle and syringe exchange i s often a first contact point. from which information about related services and activities can be offered t o new clients.

Intercambios CiviI Associahoion is a programme in Argentina, located in Avallaneda, a pour district in the south surroundings of Buenos Aires City. Outreach workers distsibute clean needles, condoms, and safer injed'on informotion to three communities with a high rate of injecting drug use and poor access t o preventive cure or medical treatment. They also develop brochures and stickers containing prevention messages, organize workhops and counsehq. Work is based on

44

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S'TfP BY !TEP - how m hilda programme

peer education and outreach. Young people are involved as outreach workers and volunteers. They participate in planning, implementation and evaluation of the programme. Kits contain two syringes, a smafl bottle of sten'le water, afilter, two alcohol swabs, a bottle cap in which to place the drug before injecting, and educational materialr about HIV prevention. For example, one of the stickers included in the sterile injection kits handed out to IDU5 says: "loco, take cure of yourself. Don't share syringes [4]. " 00-mawo-m.

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"?%e street setting means that activities are structure accarding to what is happening on f the streets. In addition to NSEP outreuch, we might Be culled to an overdose, hear of an tmoppodunity to uccess a group of new injectors, be invited to visit a squat or asked to attend to an injury. Service provision in such a setting needs to be flexible and responsible : to changing client needs on u daily bask" Source: ICON, Australia.

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Some sources suggest needle cleaning using bleach as an option for when new needles are n o t as readily available. This method had various disadvantages-it is time consuming and complicated and evidence has net been encouraging regarding its reliability. I n general, this facility should be used only as a last resort [35].

I

Remember: to start and maintain Q NSEP, you need to have a suficient number of needles and syringes, as well as a suficient number of condoms (for condom distribution).

Condom distribution As discussed i n chapter one, the lack of condom use i s an important factor i n HIV transmission within IDUs. Many IDUs practice unsafe sexual activity, rarely using condoms. Previous programmes had often preached abstinence from sexual fntercourse. This option i s

important, however it does not provide any information or support for the large number of young people who are already sexually active. Strategies must stress the importance of regular condom use, with regular as well as with irregular partners. Condoms are not always as available as ORE would expect, and financial barriers also exist. To promote safe sex, condom distribution can help. It can reduce the occasions where an IDU may not have any sexual protection available. Condoms can be distributed together with injection kits or with HIV and AIDS educational material by outreach workers. Also, together with condom distribution, IDUs can be told about the importance of condom use as wet1 as shown how t o use condoms properly.

Condom availability i s especially important for sexually active youth, for youth that do not knew where t o get condoms and for youth that can not afford t o buy condoms.

45

*

~

~

HW prevention among young ifljecting drug uwi

Condom promotion may not be as accepted as you would hope. Many people oppose condom use, feeling that they are not a t risk of becoming infected and using various reasons to avoid use.

Some issues 1331 t o be considered: Some youth may lack knowledge of how t o use condoms correctly. Pictures should accompany instructions and written material should be simple, so the target group can easily understand it. Distribution programmes can include demonstrations. (Insert example o f brochures from groups). Embarrassment: Make your condom distribution discrete-try t o avoid situations where youth will have t o explain themselves or be i n contact with adults i n order t o receive condoms. Being prepared: encourage young men and also women, t o carry condoms with them just i n case. Reduced pleasure: a common excuse for not using condoms i s the belief that condoms diminish sexual pleasure. Encourage young people t o make putting on the condoms part of the prelude t o sex. Myths: some groups believe that carrying condoms means that young people are promiscuous. Use positive peer pressure t o promote condoms.

Do not forget t o mention abstinence-just because you are distributing condoms does not mean t h a t you are pushing youth t o have sex. Make sure they are aware of their other options.

Drug using women often are involved i n commercial sex work and have a power disadvantage i n negotiating safer sex. It may be helpful for these women to have access t o female condoms.

Some more things to keep in mind while working with young injectors "Some of the most important rules of our work are the ethic rules: anonymity, confidentiality, voluntary participation in the programme, Friendly attitude t o the injectors, and peer approach." Source: Steps t o a positive direction-Initiative for Health Foundation, Bulgaria. "Of primary importance t o ICON'S client group i s the need for sewices to be delivered in a

culturally appropriate, discrete and sensitive manner. Confidentiality is of utmost importance when working with young I D U who may s t i l l be living a t home with their parents." Source: ICON, Australia.

46

Some points, other than the ones already mentioned throughout this section, which came up repeatedly i n discussion about the best ways t o work with young IDUs and ways t o improve a project, were:

Use active listening skills when working with the IDUs. Use clear and accessible language, compatible with the educational level of the user. Confidentiality and respect should be a part of the main principles of the project. Be receptive and show human warmth. Have a mix of professionals and peers i n the staff. Use a peer approach and use contacts i n the community t o spread the news about your project. Your centre should be a safe place for IDUS. Make sure police w i l l not intelfere. Be accessible, located in a place comfortable for youth, have long opening hours a t late hours, be easy t o get to.

Remember: The users are not always easy to find, and it can be a hard task to gain acceptonce from them. It's not always easy to build trust. Don'tforget that IDUs are often trying to keep away from the police and also are distrusvui of institutions. I t is not always easy to get the users to acknowfedge the prubfem, many do not believe they are at risk.

Youth friendly services

Why YFS? Many people ask why should young people have "youth friendly" sew'ces? What about old people? What about everyone having "client friendly" services? What i s the difference between client friendly and youth friendly services?

It i s true that the whole population should have access t o services that are responsive t o their needs and vary depending on age, gender, socio-economic status, ability, and ethnicity. The ultimate goal i s that a l l services should be "client friendly". There are however, three pressing reasons why youth friendly services are necessary.

Firstly, adolescence i s a period of transition and experimentation. I n many countries, young people [37] have sex for the first time and begin t o use substances such as, tobacco, alcohol, and illicit drugs. The habits and lifestyles that are established during this period have a profound effect on future health and devehpment. WHO has estimated that 70 per cent of premature deaths amongst adults are largely due t o behaviours initiated during adollescenre. I n addition, many of the lifestyles engaged i n during adolescence, such as, unsafe sex and substance abuse can facilitate the transmission of HIV, result i n unplanned pregnancy and STIS, and result i n long term addictions, or dependency on unhealthy substances. Young people (aged 10 to 24 years) thus need information, life skills and access t o sewices (such as, counselling) t o assist them i n a healthy transition t o adulthood. Young people should be assured of physical and sexua! health,

47

H1V preveation among young injecting dtug uwi

mental and emotional well-being, freedom from exploitation and abuse, skills and opportunities for sustainable livelihoods. Secondly, young people are an important resource for the future and we need t o invest i n their health and development so they are abie t o Sully participate and contribute t o society. As expressed a t the recent United Nations General Assembly Special Session on Children: "Young people are not the sources of problems-they are the resources that are needed t o solve them. They are not expenses, b u t rather investments: not just young people, but citizens of the world, present as well as the future [38]."' Thirdly, young people have rights. They have the right t o participate i n decisions and actions that afiect their lives, and to develop roles and attitudes compatible with responsible citizenship (WHO, 2000). This right builds on Article 24 of the Convention of the Rights of the Child (UN, 1989) which defines practical steps countries must take when they sign and ratify the Convention. To ensure that all children and young peopZe enjoy "the highest attainable standard of health" countries must take measures to reduce infant mortality, develop primary health care, combat disease and malnutrition, provide health information and t o develop preventive care services. After outreach work has been done, one aim could be, i f the means are available, t o set up a drop-in centre where youth can come to you. ARer they feel comfortable and have developed a strong enough trust i n your project, it would be realistic t o expect that they would agree t o come t o a fixed place a t which you are stationed. {This does not mean t h a t outreach work and going out on the streets should stop-but this i s an additional aspect of work). Such a centre should be a contact place, a safe and non-threatening space where they can fee! comfortable, and get services not only related t o drugs and HIV/AIDS, but t o other areas of their life. A drop i n centre should be located as dose as possible t o the area where drug users gather, t o increase the probability that they w i l l make use of the place. They should net have t o travel much to reach you. Consider what opening hours would be most appropriate considering your target group. Your centre may include for example: *:

m*

Counselling: Youth may want t o tallk about relationships, family, work or money. (Counselling does not necessarily have t o be provided i n a centre; it can be given after HIV/AIDS counselling or with the NSEP for example.) Vocational information: Your target group may need help finding job opportunities. Your centre couZd have listings of j o b openings fax example. To complement this, there could be an office with telephone facilities.

0

.* Life skills training: groups could be set up where youth meet t o learn and practice life skilk. * Hygiene: IDUs do not always have a place where they can shower, or rest, especially if they are street youth. Your centre could provide such facilities as a rest room, showers and

0 '

changing rooms. A medical room could also be useful. m

48

.* Referrals: A centre could have information about other services, for drug treatment, for HIV testing and counselling, for STDs.

.'. NSEP: A fixed place can also serve as a

needle exchange site, as well as a place for condom

distribution.

*: Recreation: television, games and other recreational activities could be available.

:.

Information, education and communication materials (IEC): O f c o m e any fixed place where you are stationed should have information brochures about HIV and AIDS, safe injecting practices, safe sexual practices, treatment services, legal rights and so on.

According t o a United Nations inter agency group for South Eastern Europe on youth and HIV, the essential elements of any YFHS are:

:.

General health (endemic diseases, injuries, TB, malaria).

*: Sexual and reproductive health ($TI, contraceptives, management of pregnancy, post-abortion care).

Voluntay Confidential Counselling and Testing (VCCT) for HIV.

.*. Management of sexual and domestic

:.

violence.

Mental health services. Substance abuse (alcohol, tobacco, i l l i c i t substances and injecting drug use). Information and counselling on a range of issues (sexual and reproductive health, nutrition, hygiene, substance use).

HIV testing and counselling Voluntary counsell-fng and testing is an important aspect of prevention. Youth, who have become aware of the risks of HIV, through your programme or through public awareness or friends having become sick with AIDS or through any other way, may want t o get tested for HIV. Often they will be worried and anxious, especially i f they feel they are a t high risk of having the virus and need counselling t o help them get through this time. Knowledge of the HTV status can help modify behaviours t o prevent transmission of the virus. It can also be important t o improve the general health and i n seeking treatment for opportunistic infections. Your group can refer IDUs t o HIV testing facilities, or can discuss with them the possibilities of getting tested. IDUs should be encouraged to get tested. The HIV test i s a blood test that screens for the presence of antibodies t h a t have developed i n response to the HIV. There i s a period between infection and when the test can show that a person i s infected-this i s the "window period" (this can last 2 weeks t o 6 months) during which a person will test negative although they do carry the virus. Counselling before HIV-testing helps young people assess their risk, decide whether t o be tested and consider the meaning of the positive or negative test result. The person can also discuss their fears or concerns and it can also help t o clarify why taking the test i s a good idea (not a l l individuals will admit t o high risk behaviours and may considex themselves out of risk).

49

-

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1P

HIV prevtntion among young injerting drug w r i

Counselling after HIV-testing i s also very important. It helps to interpret the results of the test. I f they are tested negative, it i s a good time to talk about reducing risk-a negative result does not mean that one will never contract the virus. A negative test result must be confronted with the possibility of the person being within the window period. If they have tested positive, they may not immediately understand the meaning of this. They need to be helped and t o realize that a positive test does not mean they wilZ die immediately, Remember that AIDS symptoms may take up t o 10 year to develop. They can learn t o improve their qualib of life and be told about possible medical care. they also need to learn how t o protect others-meaning how to avoid further spread of the virus. .e.*

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: "Christine got sick living in the streets and was placed in a hospitd where she wu5 tested : : for HIV. 'One night I overheard two nurses talking about the young girl in this bed befng HIV :

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eyes and asked her to repeot what she said, and she told me that you ; we going to die of AID5 soon. 1 cried d l day and all night and kept tbinking of suicide.'"

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The most important aspect of counselling i s confidentiality. Young people need t o feel sure that unless they give permission, the results of their test will not be disclosed t o anyone. You should refer youth t o a centre where counselling and HIV-testing can be done. Make sure that testing there is always voluntary and confidential. Remember that places you refer t o reflect on your programme-if there is no confidentiality there, youth w i l l lose trust i n your project. It is also important for youth t o go to youth-friendly services, which are open and accepting t o young people.

Young people may also want to talk about a wide range of ether problems i n counselling. They will likely be facing various problems simultaneously, with family, with money with work and so on . . . Counsellors should be open t o them, not judge them and listen to their issues. Health workers, physicians, teachers, social workers or others can provide counselling. They need training t o learn a l l the necessary skills for counseling [33].

Drug treatment sewices When there i s enough trust and a stable relationship has been built with the IDUs, they can also be referred t o drug treatment services. I f you recall the prevention hierarchy, you will remember that our main aim is abstinence from drugs, However, you should realize that you can not expect that your target group will be open or willing to go t o treatment right away. Some may never agree t o attempt treatment. Far from being disheartening, this i s a typical example of those difficult situations we all face when working on drug demand reduction issues. How do we gain the trust of our "clients", be non judgmental and yet nudge them towards seeking treatment is an operational rather than ideological problem, one that demand reduction practitioners confront every day. Substitution drug treatment: Drug treatment programmes have been found t o be effective in assisting drug users t o reduce or stop injecting, especially when they are involved i n substitution drug treatment (such as methadone or buprenorphine) [ 191. Today, substitution treatment i s

50

STEP BY 5T€P - Row to build a programme

available for heroin anU opiates, but not for cocaine dependence and many other drugs. Substitution therapy provides those with an opioid dependence with a daily dose of methadone (or other synthetic narcotic medication) i n an attempt t o help them break their addiction. Substitution programmes [35] aim to: Reduce the risk of HIV transmission; Minimize the risks of overdosing and other complications; Switch users from injection t o non-injection; Reduce polydrug use; Reduce crime associated with getting the drug; and Provide counselling and treatment t o drug users with which contact is maintained.

* "Methadone maintenance insum that the drug user comes to a treatment institute regularly. : When they're here we can offer them tests for TB, HIK and other medical services. rf they have other health problems. we can treat them. This contact i's substantial. Their status changes from being illegal and underground to being a purt of society,"

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Source: Emilis Subata, Director, * Vilnius Substance Abuse Treatment Centre, Vilnius, Lithuania [12]. ;

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Other, non pharmacological drug treatment programmes are listed below: Cognitive behavioural therapy (CBT): focuses on cognitke processes (maladaptive thoughts) and behavioural coping skills. The goal is t o diminish factors contributing t o drug involvement and promote factors that protect against relapse.

Family therapy: stress the role of the family i n developing and maintaining adolescent drug abuse. Many approaches also include peers, school and neighbourhoad, based on the idea that extended systems contribute t o dysfunctional family interactions. It focuses an inducing a family change. Therapeutic community (TC): an intensive, 24-hour setting residential treatment model developed for aduks, however modifications exist for adolescents. This form of treatment is usually resewed for the most severe abuse problems, with serious negative consequences that require long-term care. The most important characteristics are the use o f the community as a therapist and the highly structured, well-defined process QF self-reliant operation. Self-help groups: aim t o empower the person t o take responsibility and within a group get support t o help him or herself get off drugs or stay o f f drugs. These groups are often recommended as follow up after a more intensive treatment. Motivational interviewing (M€): a focused method, i n which the counsellor guides the client into reaching the desired aim. Although directive, the idea behind MI i s t o guide the client, but not t o coerce them into change. Motivation therapy can also be important, as an early intervention, t o raise the patient's motivation t o get treatment. It aims t o make the person aware of his need for treatment and often can be carried out in non-traditional settings like hospitak (if a user has tome i n due t o some physical complications).

HIV prevention among young injecting drug urerr

.'. Behavioural therapy: believes that unwanted behaviour can be modified through the demonstration of the desired behaviour and reward of steps leading towards achieving it. Methods include assignments, rehearsal of behaviours, recording and reviewing progress, and using praise and privileges for fulfilling goals. Several longitudinal studies examining changes in HIV risk behaviours for patients currently in treatment have found that longer retention i n treatment, as well as completion of treatment, are correlated with reduction HIV risk behaviours or an increase i n protective behaviours 1323.

The relationship between HIV treatment and drug treatment is also worth mentioning. One common problem that is encountered with H I V treatment is compliance. It is often difficult t o get the person to keep t o a strict regime of medication intake. It seems however, that when a person is involved i n drug treatment, especially in substitution treatment, where they have t o come i n t o the treatment centre daily to get their dose of substance, it can help t o associate the HIV treatment t o it. When they are regularly going t o get their substitution drug for example, they can a t the same time get treatment for HIV. This can enhance adherence t o the HIV medical treatment.

Life skills are also an aspect to be considered. Although providing or training life skills is not enough on i t s own, as part of a comprehensive programme, it can be beneficial for youth t o learn skills to implement the safer behaviour they learn about as well as improve their functioning i n other areas. They often lack skills for use i n other areas of life, and your programme can provide a continuum of services, including skills that relate t o areas other than drug use. The idea here i s t o give overall assistance--to help them not only reduce risk behaviours, but eventually also reintegrate into society, have social skills and be able t o get jobs. Of course it is often quite easy t o say, include life skills i n your intervention but the key is implementing it correctLy. When do you provide life skilts training? What is the setting? How are specific skills t o be introduced? What teaching techniques do we need t o use? Questions Like these are bound t o crop up when you start including life skills i n your programmes. For a good

explanation of how life skilk education must be planned and implemented please consult Skills for Health, WHO 2003, (http://www.unicef.orgJlifeskillsJSkillsForHealth230503.pdf) Examples of life skills [33] that youth would benefit from are:

,". How t o discuss safer sex with partners and rehearsal of these skills. *:

How t o properly use condoms.

,". How t o identify individuals i n the community who they can rely on for support. =:

52

How t o recognize and avoid risky situations.

ETEP BY lTEP - how to build a programme

:.

Problem solving techniques far difficult situations.

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Self esteem building.

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HQWand where t o get help and support.

How t o communicate with others i n the community. Here i s an example from the Canadian Red Cross Society [39] of excuses relating t o condom use and suggested responses that can be provided or rote-played with youth.

P

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.

.

I F YOUR PARTNER USES THIS EXCUSE ,

YOU CAN REPLY

1 can't feel anything when I wear a condom,

1know there's a toss of feeling. But there are still plenty of sensations left.

Condoms are unnatural and turn me off.

There's nothing great about disease either.

I'm insulted! You act like I'm a leper.

Not a t all. I want it because I care about relationship.

I love you. Would I give you an infection?

You wouldn't mean to, but most people don't know they're infected.

I'm afraid it will siip off and stay inside me.

Don't worry, I know how t o put it on properly so there i s no chance it will dip off.

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OUT

HIV positive youth Some young people you encounter i n your project may already be infected with HIV. Their needs are different but are also very important. They need help making decisions about their lives, they often need t o prepare for eventual illness and may need clarification t o truly understand what HIV and AIDS means. Safe sex is especially important for this population, t o prevent the virus from being passed on t o others and t o prevent their expasure t o other STD's.

HIV positive youth may find it difficult t o deal with the fact that they are infected so early i n life. They may be confused about their sex life and the risk of infecting others, They may be disconnected from friends due t o stigmatization and may not always have support from their

own family [5]. .e.*

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charged for conduct risking the transmission of the r h s , But we must be careful to avoid owr-reurthg based en misinformation and prqjudice , such situutiens can lead to a miscarJiage of justice and promete stigma und discrimination." Marika Fa hlen, * Director of Social Mabiliration and Information at UNAIDS [40j.

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53

H!I prmtion among yorng injecting drug w r i

HIV positive IDUs may encounter a double stigma-once due t o their drug use, and the second time due t o their HIV status. Social stigma must be fought, but we must realize that it won’t disappear immediately and we should be aware of the difficulties t h a t these youth may be going through. .......e*.

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“live and let h e was the slogan of the two-year Worid AIDS Cumpoign 2002-2UO3,which focused on eliminating stigma and discrimination. Stigma and discrimination are the major obstacles to efictive HIV/AIDS prevention and core. Fear of discriminotion may prevent people from seeking treatment f o r AIDS or from acknowledging their HIV status publicly. People with, or suspected of having, H I V may be turned away from health core semies, denied housing and employment, shunned by their fiends ond colleagues, turned down f o r insurance coverage or refused entry into foreign countries. In some cases, they may be evicted from home by theirfomilies, divorced by their spouses, and suffer physical violence or even murder. The stigma attached to HIV/AIDS may extend into the next generation, pLaCjng an emotiond burden on children who may also be tying to cope with the death of their parents from AIDS. With its focus on stigma and discrimination, the Campaign will encourage people to break the silence and the barriers to effectjve #IV/AIDS prevention and core. Only by confronting stigma and discrimination wit( the fight against HIV/AIDS be won 1411.’’ .mmmm.a.m.

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H I V positive youth can also become peer educators. This can give them some meaning and a sense of purpose i f they are willing t o talk t o others about their experience.

Youth who develop AIDS and become sick can be visited by the group, and supported through their most difficult times. The programme can also help by reminding them t o take medication or shopping for them i f necessary, for example. Some youth will not have family or friends t o stand by them when they are sick-in this case your programme can be especially important.

1 m

54

Remember: youth with HIV working in your project may of this reality.

become sick

suddenly-be

aware

T E IP 3Y ITP - how to build a programme

Mauricio, 24 years old, is married and has no children. He was born and lives in Porto Alegre, in Rio trande do SUI. According to a study by the Ministry of Health, HIV prevalence in lDUs in Porto AZegre is 64.3 per cent, the highest in Brazil (in Salvador for example, the rate is only 6.4 per cent].

I

Mauricio started sniffrng cocaine when he was 13 years old. He didn’t use other drugs, not even alcohol, but he quickly moved on to use crack. Although able to live with his mother at home (who was separated from his father), he lived on the street most of the time, surviving on small thefts. He continued his use, but meanwhile he “could not feel anything anymoreA and wanted something stronger. Sniffing cocaine or crack no longer satisfied him. When he was 16,he sought out a group he already knew, who were injecting cocaine users. They were all older than he was and he started injecting with them. He injected with them for 2 years before getting sick, a t 18 years. He began having persistent vomiting and headaches. He went to a hospital and was diagnosed with sinusitis. He believes he was a victim of prejudice for being a drug user: why would they attend to a drug u5er who “is a lost cause” rather than attending to a worker? His mother and sister supported him and, worried about his symptoms, took him to a private doctor. The exams showed he had meningitis, caused by the tubercutosis bacteria. Referred to the public health system in Port0 Alegre, he was cared for and weEl treated.

He was in a coma for 2 0 days and after his hospitalization still went through a terrible period, not being able to feed himself and realizing that he was seropositive with a manifesting opportunistic infection. His mother and sister supported him at all times, and without them he “wouldn’t have survived”. At this point he had to make a decision: he knew he couldn’t continue injecting drugs, he wouldn’t survive. So he made the decision between life and death. And he chose to live. As soon as his physical conditions allowed, he found a self-help group for seropositive people, He fett like his life was “useless” and that he would never find a job. In this group (GAPA--support group for prevention of AIDS), he regained his self-esteem, mainly thanks to meeting Andrea, a 39-year-old HIV positive woman working in prevention. They have been married for the last 4 years, supporting each other through treatment.

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Through her he got to know the Harm Reduction Project-supported by the National Coordination of STD/AlDS and UNODC under the National AIDS Programme-and did what he had thought impossible: he started working! Through this work he was able to take part in the global network meeting jn Cuiaba, in September of 2001. A5 for cocaine, he reports never having used again, although using marijuana lightly. Thanks to antiretroviral treatment, he is doing well and his health is stable. Currently, he is so strong that he applied for adult studying scholarships that he read about in the newspaper: in December 2002 he will be able to finish his fundarnentat education [42J,

1

55

H V I prevcntion among young injecting drug urerr

Funding, monitoring and evaluating This section w i l l be a short reference to the topic of funding and support, monitoring and evatuating your project, mentioning only some ideas and examples. More information on this topic can be found i n the Global Youth Network Project How-to guide on using peer t o peer strategies i n drug prevention. (http://www.unodc.org/youthnet/youthnet-action. html)

Funding and Support *:

Before you start, try t o find out what resources you have available t o your project. Where could you get funding? What educational materials already exist i n this field? What kind of alliances could you make with other organizations?

*:

Financial support w i l l be one o f t h e key issues when you start your project. Find out which donors may be interested i n the work of your project. Try t o approach donors early so you have time t o present them with your ideas and explain your needs. I f your project i s linked t o other organizations, they may already have donors who they work with.

.'. Funding i s often

not sufficient, and funding difficulties can make it difficult t o sustain a project and professionals may not agree t o work for no pay or low pay. You may need t o look for cooperation in the private rector or with other countries or international organizations.

Having voluntary workers i s helpful for programmes that don't have a large amount of funding. *.**m*m.

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: begun with the support of UNAIDS. Currently it is funded by the NutionaI Ministry of

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"Fully 40 per cent of all reported AIDS patients in Argentina contmcled HW when they shared syfingm in order to inject drugs. This information, collected by LUSIDA (the national programme for the fight against AIDS and sexualiy transmitted diseuses), was crjtiCa& + irnp&ant in the government's decision to offer uflciaf support to harm reduct-ron programmes [5],"

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lTEP BY STFP - Row to build a programme

Look for competitions or other opportunities t o get funding for your project. .*mmm.*..*

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In Argentina, the programme Locos de Sarandi-so named because in the language of the drug users, loco is someone who uses drug3 and careta Ijsomeone who does not-won a competition organized by the Ministry of Health and got a budget of 30,000 dollars (51. .*#.meme#*

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Evuluation and rnoniton'ng *:

Evaluation i s important t o know if your project i s going the way that you had intended or if it needs adaptations. It should allow you t o learn from experience and plan for future activities. It may also help t o gain more support and funding from the community and other organizations [33].

*: Monitoring can be carried a u t through for example: The number of syringes exchanged; Condoms distributed; Number of IDUs with which the programme came i n contact; Number of people trained (outreach workers); Brochures printed and distributed. More importantly, it i s a good idea t o monitor drug and sex behaviours and attitudes. This may be difficult t o evaluate, but w i l l provide a Lot of information for your programme.

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it i s important t o monitor how IDUs are perceived by the community t o ascertain i f the programme i s managing t o change the negative image that usuaHy surrounds IDUs.

*: Evaluations can be carried out by external consultants or through internal agency reports. They can be done through supexvisoly meetings, conversations with youth involved, surveys, evaluation, outreach workers feedback, outreach workers can keep logs. m.o*mmmme*

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In a research canducted by Fabia Mesquita in the metropolitan area of Santos, it was observed that HIV infem'on rates lowered from 65 per cent in 1996 to 42 per cent in 1999. ResuIts within the group also showed that in the month of August 2000, 632 syringes were exchanged among IOUs. In the following year, however, (ZCIOI), 3,636 syringes were exchanged on overage per month, showing a considerable increose between the two years. .em*mmmmeaa

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K ~ Yprinciple! for HIVprevention \ How t o build a programme The most recommended way to go about prevention is t o provide a comprehensive package of care, including information and education, life skills training, condom distribution, access t o clean needles and syringes, voluntaly and confidential HIV testing and counselling, referrals for a variety of treatment options and more.

Know the target group It is important t o know the group you are working with. Do not [et lack of information stop you from getting started, however keep i n mind that the more you know, the more chances you will have t o reach your target group.

Before you start, try t o get as much information as possibte about: their demographics, injecting behaviour and patterns, sexual behaviour and the HIU/AIDS situation i n their population.

Staff Staff wha are going t o work with young IDUs should be open, non-judgmentat$ understanding, sensitive and respectful.

59

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tflV prevcntios among young injecting dntg um

Staff can be users, ex-users or non-users. Each group has advantages and disadvantages that should be considered. Using peers t o talk t o youth is considered a useful and important method i n prevention programmes. Young peopie are likely t o listen t o their peers more than t o adults.

PEanning and involving youth Involving youth is a key aspect of a programme targeted a t youth. They can help design the programme i n the most appropriate way. Youth can, and have been successfully involved i n all aspects of programmes, from planning and developing the programme t o implementation. When youth are involved in planning and implementing a programme, they feel a sense of ownership and responsibility towards the project.

Community Support from local authorities and communities has been shown t o be very important. Try t o consider which groups or peopie could help you or could create resistance t o your project. Far example, police and law enforcement officials could be a barrier t o reaching young people. Contact these authorities and talk t o them about your project. The general population may have reservations concerning work with IDUs due t o stigma and stereotypes. T y t o build partnerships and t o involve the community at large when possible. Since IDLls are often contacted through outreach, it dll be difficult t o have contact t o their families, considering that their confidentiality i s a high priority. However, when possible, involving the family i s a positive step.

Establishing contact IDUs will usually not come looking for you, so after you have made some contacts, you have t o go t o where they are. When you have contact with some people, they can introduce you t o others.

It is important t o use the language that the target group uses and have your information i n a form they Will be able t o d a t e to. Using the peer network is important here. Making contact i s a process of building trust, and you need t o show you are worthy of their trust.

Non-injecting groups

60

Prevention efforts in the direction of abstinence, preventing the transition t o injection as well as safe sexual behaviour is important for this group. The transition t o injection can be prevented.

IDUs Outreach: This method is one of the most important i n working with IDUs, and aims t o reach young people who are not reached by conventional services by going t o where they are and making contact. Informa~on:Youth need t o know the facts about HIV and AIQS and about risk behaviour. Information should be easy for the target group t o understand, attractive and short. Needle and Syringe Exchange Programmes: Concrete services like NSEPs are important for IDUS. The idea i s t o distribute clean injecting equipment t o reduce sharing. location and operation hours are important t o consider. This, like other services (Le. condom distribution, etc.) i s also used as an entry point t o offer IDUs counselling and treatment options. Condom distribution: Lack of condom use i s common within IDUs, so this service is important for sexually active youth. It can pxomote safe sexual activity by overcoming barriers such as avaihbility and financial issues as well as providing information about proper condom use. Other things to keep in mind while working with young injectors: Anonymity, confidentiality and sensitivity are important. Using active listening skills, clear and accessible language and being accessibly located, are also important for youth.

Youth friendly services: When trust has been established with the group, through outreach, IDUs may feel comfortable corning t o a drop-in centre where you are stationed. Such a place must be a safe and comfortable place, iocated near t o where injectors gather. Sem'ces could include counselling. life skills training, hygiene, referrals, NSEP, information, recreation and more. HIU testing and counselling: Voluntary H I V testing i s an important aspect of prevention and it should be encouraged. Counseliing before and after the test i s vital t o help youth understand

the meaning of their results and its consequences.

Drug treatment services: When a trusting relationship exists, IOUs can be referred t o drug treatment services. Remember that abstinence i s our highest aim. However, this may not happen very quickly. Various treatment methods are available. Life skills: As part of a comprehensive programme, it can be beneficial for youth t o learn skills t o irnpkment the safer behaviour they learn about as wetl as improve their funch'oning i n other areas.

WIV positive youth Their needs are different but are also very important. They need help making decisions and may need clarification t o truly understand what HIV and AIDS means.

Safe sex is especially important for this papulation; t o prevent the virus from being passed on t o others and t o prevent their exposure t o other STD's, H N positive IDUs may encounter a double stigma-once time due t o their HIV status.

due t o their drug use, and the second

61

HIV preventioi among young injecting drug u w i

Funding and support Financial support w i l l be one o f the key issues when you start your project and organizations that would like t o be involved.

. . . look for donors

Geth'ng support from government and authorities may atso not be easy, but should be worked on.

Evaluation and monitorfng Don't forget t o evaluate your programme direction.

. . . you want t o know if you are going i n the right

You can look a t number of syringes exchanged, how many IDUs you have been i n contact with, and many other indicators. More importantly, try t o get information on injecting, sexual behaviour and attitudes towards drugs.

62

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Some Useful Internet Sites Dealing with Drug Use and HIVSAIDS UMAIDS: http://www. unaids. org WHO HIV/AIDS Department: http://who.int/health-topics/hiv.htm WH 0 Substance Abuse: http://who.i nt/substa nce-ab use/ LINODC-Demand

Reduction: http://www.odccp.org/drug-demand-reduction.htrn1

The Journal of the American Medical Assodation: JAMA HIV/AIDS Resource Center: http://www.arna-assn.org/special/hiv/

American International Health Association: http://www.ai ha.com/english/health/hiv,htm Amfar: American Foundation for AIDS Research: http://www.amfar.org/ Harm Reduction CoaIition (US): http://www.harmreduction.org/

CDC-Centre

for Disease Control and Prevention (statistics om HIVJAIDS): http://www.sdc.gov

Family Drug Support (Australia): http://www.fds. 0rg.au/rnain-news. htm I

HIV InSite: h~p://hivinsite.ucsf.edu/

62

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HI! prevention among young injeMg drug ujeri

European Center on AIDS: http://www. ceses. org/aids. ht m European Monitoring Centre for Drugs and Drug Addiction: http://www.emcdda.org/ Asian H a m Reduction Network: http://ahrn.net/ Advocates for Kouth: http://www.advocatesforyouth.org/ Centre for Harm Reduction (Australia): http://www.chr.asn.au/ Drug User Organisations International (Netherlands): http://www.drugusers.org/ International Harm Reduction Development { US/CEE): http://www.soros.erg/harm-reduction/ Methadone Maintenance: Guide for Physicians (US): http://www. caas. brawn.edu/ATTC-N E/pubs/OBQT/ Narcotics Anonymous: http://na. org/i ndex. htrn

The Lindesrnith Centre Online Library (US): http://www.lindesmith.org/library/lib2.html

UNDP Regional Programmes on HIV/AIDS i n Asia/Pacific: h t t p ://www. hivundp.apdi p. net/

Centre for Research on Drugs and Health Behaviour, Department of Social Science and Medidne, Imperial College on Science, Technology and Medicine, London: http://www.med.ic.ac.uk/divisions/64/about.asp Drug Abuse Treatment Outcome Studies: http://www.datos.org/

Dragon Whispets and Cabragirlz project, Austrafia: http://home.ipri rnus. co m.au/avwwa/

64

! 1

Note!

1. AIDS Epidemic Update, December 2003, UNAIDS. 2. Young People and HIV/AIDS, A UNICEF Factsheet, February 2002. 3. Repart

on the global HIVJRIDS epidemic, June 2000, UNAIDS, Geneva.

4. Fluk, H. (2001) Syringes to go: A program in Avellaneda to use drugs w f t h c u t risks. Buenos Aires, Sunday, April 8 2001. http://www.paginal2.com.ar/~OOl/Ol-04/Ql-O~-O8/pagZl. htm 5. UNAIDS (199). Young People and HIV/AIDS: UNAIDS briefing paper. Listen, Learn, Live! World AIDS campaign with children and young people. Geneva.

6. Fact Sheet on An overview of the HIV/AIDS epidemic, UNGASS on HIV/AIDS, June 2001. 7. UNAIDS. UNODC.

(2OOQ) Drug Abuse-HIV/AIDS:

A devastating Combination.

8. Maher, L., Sargent, P. et al. (2000). Sharing Knowledge t o Protect our Cornmunfty: A pilot program for research, risk reduction and peer education with Indo-Chinese drug users. Research Development Monograph, No.1, 2000. UNSW Centre for International & Multicultural Health (University of New South Wales).

9. UNAIDS Press release 2 Juty 2002, New York/ Geneva. Major UN study Hnds alarming lack on knowledge about HIV/bIDS among young people. http://www. unaids,org/whatsnew/press/eng/pressarcO2/i ndex.htm I

10. UNAIOS Press Backgrounder, 12 May 1999, Kiev. Structural collapse sets t h e scene for t h e rapjd spread of HlV/AIDS among young people i n Eastern Europe.

65

H W prevention among young injecting drug uren

11. Des Jarlais, D.C., Dehne, K., and Casabona, 3. (2001). HIV sumei2lance among injecting drug users. AIDS, 1 5 (SUPP~3$: S13-SZ2. 12. Open Society Institute, International Harm Reduction Development 12001). Drugs, AIDS, and Harm Reduction-How to slow the HIV epidemic i n Eastern Europe and the former Soviet Union.

13. Dragon whispers and Ca bragi rlz homepage: http://herne.iprimus. com .au/avwwa/index-frameset. htrn 14. Economic and Social Commission for Asia and the Pacific (ESCAP), UNODC regional centre for East Asia and the Pacific, UNAIDS Asia Pacific Intercountry Team. Injecting Drug use and HIV vuhnerabitity: Choices and Consequences i n Asia and the Pacific. Report of the Secretay-General for the special session o f the general assembly on HIVJAIDS.

15. Maher, L. (2002). Don't leave us this way: ethnography and injecting drug use in the age o f AIDS. International Journal of Drug Policy; 311-325. 16. Wines, M. Easy Heroin Dmpr a Viral Bomb on Russia's Irkutsk. Internathional Herald Tribune, Tuesday, April 25, 2000. 17. UNAIDS, UNICEF, (1998). Young people's voices on SIIV/MDS: A communication for development

workshop, 16-19 November, 1998, New Qelhi, India.

18. Uwakwe, C.B.U., A.A. Mansaray, and G.O.M. Onwu. (1994). A Psycho-educational program to motivate and foster AIDS preventive behaviours among female Nigerian university students. Final technical report. women and AIDS research Program (unpublished). Washington DC. In: Weiss, E. Whelan, 0. and Gupta, 6.R.-International Center for Research on Women (JCRW). (1996). Vulnerability & Opportunity: Adolescents and HIV/AIPS i n the developing world. Findings from the Women and AIDS research program. Washington. 19.

Burrows, 0. and Alexander, G. (2001)- Walking on Two legs: A dwelopmental and emergency response to HIV/AIQS among young drug users in the CEE/tIS/Baltic's Regions. A Review Paper. Prepared for the UNICEF regional office for CEEJCISJBaltics, Geneva.

20. UNODC ROSA (Regional Office for South Asia). Drug use and HIV vulnerability-towards strategy for young people.

a regional

O'Hara, M. and Sowers, K.M. (2000). "Profile-based intervention: Developing gendersensitive treatment for adolescent substance abusers." Research on social Work Practice, 10 (3): 327-347.

21. ElZis, R.A.,

22. Nota, A.R., Nappo, S., Galduror, J.C.F., Matte;, R., Carlini, E.A., 111 Levantamento sobre o Us0 de Orogas entre Meninos e Meninas ern Situacao de Rua de Cinco Capitais Erasileiras. Centro BrasiZeiro de Informacoes sobre Orogas Psicotropicas-CEBRID, 1-97. 1993. 23. D e b , H. (2002). Infrequent injecting drug users: research and interventions with young people a t risk of HIV, with special focus on CEE/IS and the Baltics. Internship assignment, UNAIDS

Vienna.

S., (2002). Prison Rapes Spreading Deadly Diseases. Originally published by United Press Internutiand, July 26, 2002. http://www.vachss.com/help-text/archiveJprison_~apes. ht ml

24. Mitchell,

25. G. Medley, K. A. Dolan and G.V. Stimson, "A model of HIV transmission by syringe sharing i n EngEiJ prisons using surveys of injecting drug users", presentation a t the Eighth International Conference on AIDS, Amsterdam, July 1992. I n P.C. Des Jarlais, S.R. Friedmann. (1993). Critical issues regarding AIDS among injecting drug users. ODCCP BuIletin on Nurcotics, Issue 1 -004. http://www.odccp,org/odccp/bulleti~/bulletin~1993-01-01~l~page005. html#nu05 26. Carbone, D.J., (2001). Under Lock and Key: Youth Under the Influence of HEV. Body Positive, May 2001, Volume XIV, Number 5. http://www.thebody. comJbp/mayOl/feature_O2. ht ml

66

27. Safe Schools Coalition o f Washington. Safe Schools Anti-Violence Documentation Project: Third Annual Report. [s.l.]: the Coalition, 1996. In: Advocates for Youth: The facts: Lesbian, Gay, Bisexual and Transgender Youth-at risk and underserved. http://www.advocatesforyouth.org/publicatio~~/fa~he~t/~glbt.htm~6 28. Hetrick-Martin Institute. Lesbiun, Guy, ond BisewuaI Youth. [Fact File] New York: The Institute, 1992. In: Advocates for youth: The facts: HIVjSTO prevention and Young Men who have sex with men. http://www.advocatesforyouth.or~/pub(ications/ia~/y~sm. htm#15

29. Centers for Disease Control & Prevention. US. HIV and AIOS cases reported through June 191)J. HIVMD5 Surveillance R e p o ~1997; 9(1):1-39. In: Advocates for youth: The facts: Young Men who have sex with men: a t risk for HIV and STDs. http://www.advocatesforyouth .org/publications/factsheet/fsyngrnen.htm#4

30. Valleroy C, et al. HIV and Risk Behavior Prevalence among Young Men Who Have Sex with Men Sampled in Six Urban Counties in the USA. Presented t o the 11th International Conference on AIDS. Atlanta, GA: CDC, 1996. In: Advocates for youth: The facts: Young Men who have sex with men: a t risk for HIV

and STDs. http://www.advocatesforyovth.org/publications/facheet/Fsyngmen,

htm#4

31. Macieira M, Messina S. The invisible minority: lesbian and gay youth. PSAYNetwork 1994; 2(1):7-8. Advocates for youth: The facts: HIV/STD prevention and Young Men who have sex with men. http://www.advocatesforyouth.org/~~blfcatfons/iag/ymsm. ht m#l5

In:

32. United Nations. (2000). Prwenting the transmission of HIV among drug abusers: A position paper of the United Nations System. Annex t o the report of the eighth session o f ACC subcommittee on drug control. 33. World Health Organization, Commonwealth Youth Programme and UNICEF. (1995). Working with young people-a guide to preventing HIV/AIDS and STD's. London, Commonwealth Secretariat.

34. Higgs, F., Maher, L., Jordens, J., Dunlop, A., & Sargent, P. (2001). H a m reduction and drug users of Vietnamese ethnfdty. Drug and Alcohol Review 20, pp 239-245. 35. Asian Harm Reduction Network (2000). Prevention of HIV transmission among drug users: a training module for field-level activities. UNAIDS Asia-Pacific Intercountry Team. http://a hrn .net/powerpt/i ndex. htm 1

36. Weiss, E. Whelan, 0. and Gupta, G.R.-International Center for Research on Women (ICRW). (1996). Vulnerability & Opportunity: Adolescents and HIV/AIDS i n the developing world. Findings from t h e Women and AIDS research program. Washington.

37. The UN defines young people as aged IO t o 2.4 years, adolescents as 10 t o 19 years and youth as aged 15 t o 24 years. 38. Paraphrase of the Message from the Children's Forum, delivered t o the UNGASS on Children by child delegates-Gabriela Azurdy Arfeta and Audrey Chetnut on 8 May 2002.

39. Youth and AIDS; Workshop Guide The Canadian Red Cross Society, 1991. In: World Health Organisation, Commonweakh Youth Programme and UNICEF. (1995) Working with young people-a guide to preventing HIV/AIDS and STDs. London, Commonwealth SecretarFat.

40. UNAIDS Press release 1 0 July 2002, Barcelona. Avoid using criminal law for HIV, says new UNAIDS report. http://www. unaids.org/whatsnew/press/eng/pressarcOZ/i ndex. ht ml 41. UNAIDS World AIDS Campaign 2002-2003. http://www. unaids.org/wac/2002/i ndex-en. htm 1

42. Courtesy of the Harm reduction programme of Port0 dlegre City, Brazil, i n cooperation with UNODC field oSh'ce Brazil. (2002).

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Today HIV/ AIDS is one of the biggest challenges facing the world. The risk of getting the virus is particularly high for young injecting drug users, who are isolated, marginalized and often lack access to even basic prevention services This publication focuses on reaching out to young drug abusers with information, services and structures that are appropriate to their needs and how Civil Society at large can contribute.

HOW TO OBTAIN UNITED NATIONS PUBLICATIONS United Nations publications may be obtained from bookstores and distributors throughout the world. Consult your bookstore or write to: United Nations, Sales Section, New York or Geneva.

COMMENT SE PROCURER LES PUBLICATIONS DES NATIONS UNIES Les publications des Nations Unies sont en vente dans les librairies et les agences ddpositaires du monde entier. Informez-vous aupr5s de votre libraire ou adressez-vous ik Nations Unies, Section des ventes, New York ou Gen5ve.

C6MO CONSEGUIR PUBLICACIONES DE LAS NACIONES UNIDAS Las publicaciones de las Naciones Unidas e s t h en venta en librerias y casas distribuidoras en todas partes del mundo. Consulte a su librero o dirijase a: Naciones Unidas, Secci6n de Ventas, Nueva York o Ginebra.

Printed in Austria V.04-54807-A~g~~t 2004-800 United Nations publication Sales No. E.04.Xl.20 ISBN 92-1-148190-2

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